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GUIDE FOR ICD-10’S AND AMBULANCE SERVICES Amanda Jimeson, CPC, CAC Angela Lehman, RHIA Rebecca B. Williamson, BA, RN, NRP
GUIDE FOR ICD-10’S
AND
AMBULANCE SERVICES
Amanda Jimeson, CPC, CAC
Angela Lehman, RHIA
Rebecca B. Williamson, BA, RN, NRP
TABLE OF CONTENTS Contents
ICD-10-CM’s ______________________________________________________________________________________________ 1
ICD-10-CM Concepts _____________________________________________________________________________________ 7
General Mapping Equivalence __________________________________________________________________________ 22
Condition Codes _________________________________________________________________________________________ 25
Payor Specific ____________________________________________________________________________________________ 26
Understanding Medical Terminology __________________________________________________________________ 31
Anatomy and Physiology________________________________________________________________________________ 32
Vocabulary _______________________________________________________________________________________________ 33
Abbreviations ____________________________________________________________________________________________ 42
Understanding Lab Values and Vitals __________________________________________________________________ 49
Medications ______________________________________________________________________________________________ 54
Symptoms, Signs and Abnormal Clinical Laboratory Findings ______________________________________ 56
Great Resource __________________________________________________________________________________________ 62
Certain Infectious and Parasitic Diseases _____________________________________________________________ 63
Diseases of Blood, Blood-Forming Organs or Hemorrhage __________________________________________ 64
Endocrine, Nutritional and Metabolic Diseases _______________________________________________________ 66
Behavioral Health _______________________________________________________________________________________ 85
Diseases of the Nervous System ________________________________________________________________________ 98
Diseases of the Circulatory System __________________________________________________________________ 119
Diseases of the Respiratory System __________________________________________________________________ 143
Diseases of the Digestive System _____________________________________________________________________ 156
Disease of the Skin and Subcutaneous Tissues _____________________________________________________ 160
Diseases of the Musculoskeletal System _____________________________________________________________ 164
Genitourinary __________________________________________________________________________________________ 169
Pregnancy, Childbirth and the Puerperium _________________________________________________________ 174
Injury, Poisoning and Certain Other Consequences of External Causes ___________________________ 178
External Causes of Morbidity _________________________________________________________________________ 189
Factors Influencing Health Status and Contact Health Services ___________________________________ 190
Documentation ________________________________________________________________________________________ 192
TABLE OF CONTENTS Moving Forward _______________________________________________________________________________________ 195
Resources ______________________________________________________________________________________________ 200
Appendix _______________________________________________________________________________________________ 203
ICD-10-CM’S
Page 1
ICD-10-CM’s
OVERVIEW
The International Statistical Classification of Disease and Related Health Problems, ICD-
10, is a medical classification system for coding of:
Diseases
Injuries
Symptoms
Procedures and more
This is the first major change in U.S. coding in more than 30 years.
Some call it healthcare’s version of Y2K.
Expands diagnosis code selections to 68,000+ compared to 14,000 ICD-9-CM selections.
CURRENT REGULATION
Effective January 1, 2012, ICD-9’s were required to be submitted on electronic ambulance
claims to represent a patient’s condition. The determination of what is submitted is based
on the Medicare Administrative Contractors (MAC’s).
• Option 1: Suppliers may choose codes from the Medical Conditions List provided
by the Centers for Medicare & Medicaid Services (CMS) that corresponds to the
condition of the beneficiary at the time of pickup and report the codes in the
diagnosis field on the claim. The codes in the Medical Conditions List are taken from
the ICD-9-CM diagnosis code set.
ICD-10-CM’S
Page 2
• Option 2: Suppliers may report an ICD-9-CM (or ICD-10-CM when appropriate)
diagnosis code that is provided to them by the treating physician or other
practitioner.
• Option 3: Suppliers may report ICD-9-CM diagnosis code 799.9 unspecified illness.
• Some ambulance services submit ICD-9 codes based on their MAC’s local coverage
determination policy (LCD).
COMPLIANCE DATE
On August 24, 2012, the Department of Health and Human Services (HHS) issued a Final
Rule that delayed the compliance date for the new ICD-10 diagnosis and procedure codes
until October 1, 2014.
The previous compliance deadline of October 1, 2014 was delayed again when President
Barack Obama signed a new law on April 1, 2014. This law ordered HHS to not set an ICD-
10 deadline any sooner than October 1, 2015. The U.S. Department of Health and Human
Services (HHS) issued in September 2014, a rule finalizing Oct. 1, 2015 as the new
compliance date for health care providers, health plans, and health care clearinghouses to
transition to ICD-10.
Any provider covered by the Health Portability and Accountability Act (HIPAA) must make
the transition to ICD-10’s (MLN Matters Number SE1239).
Claims for services provided on or after the compliance date should be submitted
with ICD-10 diagnosis codes.
Claims for services provided prior to the compliance date should be submitted with
ICD-9 diagnosis codes.
ICD-10-CM’S
Page 3
DEPARTMENT OF HEALTH AND HUMAN SERVICES
MEDLEARN Matters-SE 1409
Effective October 1, 2015
ICD-10 Claims Submission Alternatives
For from dates of services for professional and supplier claims, or discharge dates
on institutional claims on or after October 1, 2015 entities covered under the Health
Insurance Portability Act (HIPAA) are required to use the ICD-10 code sets adopted
under HIPAA.
If a provider or supplier is unable to complete the necessary system changes to
submit claims with ICD-10 codes by October 1, 2015, or find they are unable to
submit claims on or after October 1, 2015, due to issues with their billing software,
vendor, or clearing house, the following claims submission alternatives are
available:
NOTE: claim submission alternatives still REQUIRE the use of ICD-10 code sets for FROM
dates of service (on professional and supplier claims) or date of discharge (on institutional
claims) on or after October 1, 2015.
Free Billing Software
• Free billing software is offered by CMS via the Electronic Data Interchange
(EDI) via each MAC’s website.
• This billing software only works for submitting Fee-for-Service claims to
Medicare. It is intended to provide submitters with an ICD-10 compliant
claims submission format; it does not provide coding assistance.
NOTE: Submitting electronic claims to Medicare using the free billing software does not
change the requirement for ICD-10 compliant claims to be submitted for FROM dates of
ICD-10-CM’S
Page 4
service on or after October 1, 2015. Any claims containing ICD-9 codes for FROM dates of
service on or after October 1, 2015, will be rejected by Medicare.
Direct data entry
• Providers that bill institutional claims are also permitted to submit claims
electronically via direct data entry (DDE) screens. For more information about
DDE, go to http://medicare.fcso.com/Direct_data_entry/.
• A request to submit claims via DDE must be done by prior to October 1, 2015.
Please note that claims submitted via DDE must contain ICD-10 codes for dates of
discharge/through dates on or after October 1, 2015. Those submitted containing ICD-9
codes for dates of discharge/through dates on or after October 1, 2015, will be returned to
provider (RTP).
Paper claims
• In limited situations, provider and suppliers may submit paper claims with
ICD-10 codes to Medicare. To find more information on when you may
submit paper claims, visit
http://www.cms.gov/Medicare/Billing/ElectronicBillingEDITrans/ASCAWai
ver.html
• A wavier must be submitted before October 1, 2015.
NOTE: Submitting paper claims to Medicare, even if approved for an ASCA waiver, does not
change the requirement for ICD-10 compliant claims to be submitted for FROM dates of
service (on professional and supplier claims) or dates of discharge/through dates (on
institutional claims) on or after October 1, 2015.
Letter from CMS
On July 6, 2015, CMS provided a letter to providers and suppliers detailing that CMS will
be:
ICD-10-CM’S
Page 5
Flexible in claims auditing and quality reporting process.
CMS will set up a communication and collaboration center for monitoring the
implementation of ICD-10’s.
CMS will create an ICD-10 Ombudsman to help triage physician and provider issues.
Further information can be found at www.cms.gov/ICD10.
GEARING UP FOR CHANGE
Change is not easy to embrace, even if the outcome is for the better.
Reasons for change:
o We have to change because the current process is broke; or
o There is a better way to accomplish a task or goal.
WHY THE CHANGE?
Clinical
Better outcomes because of better documentation.
Paints a better picture due to specificity, laterality, and more detailed information
about the disease process.
Improvement of care due to the documentation on higher acuity patients.
Help to design better protocols.
Provides more precise information reporting to the State and other Public Health
entities.
Improved tracking of patient illnesses.
Provides more data for research to develop better patient outcomes; current
system (ICD-9) is archaic compared to other countries.
Operational
Improved definitions of patient conditions.
ICD-10-CM’S
Page 6
For institutional providers, helps with greater specificity to define co-morbidities
and complications.
The ability to share better data based on patient and population.
Financial
Better documentation, which gives ability to understand the patient complexity and
level of care; therefore, supporting reimbursement for the level of care provided.
Allows for better comparison for benchmarking patient conditions.
May aid in lowering audits due to more specific codes supported by greater
documentation.
ICD-10-CM CONCEPTS
Page 7
ICD-10-CM Concepts
ICD-9-CM
Only 17 Chapters
ICD-10-CM
21 Chapters
ICD-10-CM CONCEPTS
Page 8
DOCUMENTATION FOCUS AREAS
Disease type
Disease acuity
Disease stage
Site specific
Laterality
Combination Codes
Changes in timeframes with certain codes
DIFFERENCES
ICD-10-CM CONCEPTS
Page 9
ICD-10-CM CONCEPTS
Page 10
ICD-10-CM CONCEPTS
Page 11
ICD-10-CM CONCEPTS
Page 12
INITIAL VS. SUBSEQUENT VS. SEQUELA
Initial Encounter is While Receiving Active Treatment
o Surgical treatment
o Emergency treatment
o Those who seek a delay in treatment.
Subsequent has completed active care and now in the healing processes.
o Cast change
o Removal of devices
o Follow-up doctor’s visits
Sequela
o Late effect
o A chronic or residual condition that is a complication of an acute condition
that occurs after the acute disease, illness or injury.
ICD-10-CM CONCEPTS
Page 13
ICD-10-CM CONCEPTS
Page 14
ICD-10-CM CONCEPTS
Page 15
ICD-10-CM Official Coding Guidelines
The Centers for Medicare and Medicaid Services (CMS) and the National Center for
Health Statistics (NCHS), two departments within the U.S. Federal Government’s
Department of Health and Human Services (DHHS) provide the following
guidelines for coding and reporting using the International Classification of
Diseases, 10th Revision, Clinical Modification (ICD-10-CM).
These guidelines should be used as a companion document to the official version of
the ICD-10-CM as published on the NCHS website.
These guidelines have been approved by the four organizations that make up the
Cooperating Parties for the ICD-10-CM:
o The American Hospital Association (AHA),
o The American Health Information Management Association (AHIMA),
o CMS, and
o NCHS.
Adherence to these guidelines when assigning ICD-10-CM diagnosis codes is
required under the Health Insurance Portability and Accountability Act (HIPAA).
The diagnosis codes (Tabular List and Alphabetic Index) have been adopted under
HIPAA for all healthcare settings.
ICD-10-CM CONCEPTS
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ICD-10-CM CONCEPTS
Page 17
ICD-10-CM CONCEPTS
Page 18
ICD-10-CM CONCEPTS
Page 19
ICD-10-CM CONCEPTS
Page 20
ICD-10-CM CONCEPTS
Page 21
GENERAL MAPPING EQUIVALENCE
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General Mapping Equivalence
Identification of potential corresponding codes between ICD-9 and ICD-10.
Mappings are bi-directional, and goes backwards and forwards.
GEMS are not direct crosswalks; there is not an exact match between more complex
ICD-10-CM codes.
This may limit the likely hood of an exact match.
A single ICD-9 code may map to multiple ICD-10 codes.
o There are new concepts in ICD-10 codes that were not available in ICD-9
codes.
o More than one ICD-9-CM Code may be possible translation of a given ICD-
10-CM.
GENERAL MAPPING EQUIVALENCE
Page 23
o More than one ICD-9-CM Code may be required to convey the complete
meaning of a given ICD-10-CM.
NATIVE CODING AND UNSPECIFIED CODES
Native coding means to assign an ICD-10 diagnosis code directly based on clinical
documentation.
Providers are encouraged to natively code using ICD-10 code reference sources
instead of using crosswalks, which should be used for general knowledge.
Specific codes reflecting the most appropriate level of certainty known for an
encounter should be evaluated first:
o Specific diagnosis codes should be reported when they are supported by the
available medical record documentation and clinical knowledge of the
patient’s health condition.
o If the end of the encounter has not established a definitive diagnosis, it is
appropriate to report codes for sign(s) and/or symptom(s) in lieu of a
definitive diagnosis.
o When sufficient clinical information is not known or available about a
particular health condition to assign a more specific code, coding should
comply with the payer guidelines for the use of unspecified codes.
GENERAL MAPPING EQUIVALENCE
Page 24
CONDITION CODES
Page 25
Condition Codes
PAYOR SPECIFIC
Page 26
Payor Specific
Workers’ compensation and auto insurance companies are considered non-covered
entities under HIPAA. Will they have to switch to ICD-10-CM?
Answer: Workers' compensation and auto insurance companies are considered non-
covered entities and are not covered under HIPAA; however, since the ICD-9-CM codes
will no longer be maintained after the implementation of ICD-10-CM it is recommended
that that they use the new coding system.
Payor Specific Information is based on information available as of July 1, 2015.
PAYOR SPECIFIC
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PAYOR SPECIFIC
Page 28
PAYOR SPECIFIC
Page 29
PAYOR SPECIFIC
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UNDERSTANDING MEDICAL TERMINOLOGY
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Understanding Medical Terminology
Medical billers and medical coders need to be comfortable using and understanding medical terms in order to apply the correct codes to describe services delivered to patients.
Very often within the clinical environment, medical terminology is composed of abbreviations and understanding them makes reading documentation much faster and easier.
Many of the words used by physicians, surgeons, and other healthcare providers consist of Greek and Latin root words that are combined to create a multi-syllabic term that carries a precise meaning.
Most medical terms consist of three basic components:
o root word (the base of the term),
o prefixes (letter groups in front of the root word) and
o suffixes (letter groups at the end of the root word).
For example, the term sub hepatic, “sub” is the prefix meaning “below or under.”
The word root hepat-means “liver” and the suffix –ic means “pertaining to”.
While a medical biller or coder knows what a layperson means when they say that
someone has suffered a heart attack, this term means nothing for coding or billing
purposes.
Medical terminology precisely defines a condition. Professional medical billers are
able to understand the specifics of this terminology in order to communicate it to
third-party payers for accurate reimbursement.
Some of the more commonly used words for EMS documentation are included in
the next few pages.
ANATOMY AND PHYSIOLOGY
Page 32
Anatomy and Physiology
Anatomy
Study of normal body structures.
Physiology
Study of normal, healthy, bodily functions.
Pathophysiology
Study the changes of normal mechanical, physical and biochemical functions.
By understanding the basics of A&P, Billing and Coding can:
• Gain understanding how diseases affect healthy functions of the organs and
body system.
• Be better equipped to ask intelligent questions if they need query the
documentation for clarity to ensure appropriate level of billing.
VOCABULARY
Page 33
Vocabulary
a- no; not; without an- no; not; without ab- away from ad- toward -ad toward aden/o gland -al pertaining to -algia pain all/o other amphi- around, on both sides, about
-an pertaining to
andi/o vessel (blood)
ante- before; forward
anter/o front
anti- against
-ar pertaining to
arter/o artery
arteri/o artery
arthr/o joint
-ary pertaining to
-ation process; condition
axill/o armpit
bi- two
bi/o life
bil/i bile; gall
brady- slow
cac/o bad
carcin/o cancerous; cancer
cardi/o heart
-centesis surgical puncture to remove fluid
cephal/o head
chem/o drug; chemical
-chezia defecation; elimination of wastes
chol/e bile; gall
VOCABULARY
Page 34
chondr/o cartilage
chrom/o color
-cide killing
circum- around
cis/o to cut
con- together with
consci/o awareness; aware
contra- against; opposite
contus/o to bruise
coron/o heart
corpor/o body
cost/o rib
crani/o skull
cutane/o skin
cyan/o blue
cyst/o urinary bladder; cyst; sac of fluid
-cyt/o cell
-cytosis condition of cells; slight increase in numbers
de- lack of; down; less; removal of
derm/o skin
-derma skin
-desis to bind; tie together
dextr/o right
dia- complete; through
-dilation widening; stretching; expanding
dilat/o to enlarge; expand
dipl/o double
dis- apart; to separate
dist/o far; distant
dolor/o pain
dors/o back (of body)
dorsi- back
-dote to give
duct/o to lead; carry
-dynia pain
VOCABULARY
Page 35
dys- bad; painful; difficult; abnormal
-eal pertaining to
ec- out; outside
-ectasia/s dilation; dilatation; widening
ecto- out; outside
-ectomy removal; excision; resection
-edema swelling
em- in
-ema condition
-emesis vomiting
-emia blood condition
-emic pertaining to blood condition
-en in; within
encephal/o brain
end- in; within
endo- in; within
enter/o intestines (usually small intestine)
epi- above; upon; on
epitheli/o skin; epithelium
equi- equality; equal
-er one who
erythem/o flushed; redness
erythro red
-esis action; condition; state of
eso- inward
eti/o cause
eu- good; normal
ex/o- out; away from
extra- outside
fore- before; in front
-form resembling; in the shape of
frig/o cold
-fusion to pour; to come together
gastr/o stomach
-gen substance that produces
VOCABULARY
Page 36
-genesis producing; forming
-genic produced by or in
ger/o old age
gest/o pregnancy
gloss/o tongue
gluc/o glucose; sugar
glyc/o glucose; sugar
-grade to go
-gram record
-graph instrument for recording
graph/o writing
gravid/o pregnancy
gynec/o woman; female
hapl/o simple; single
hem/o blood
hemat/o blood
hemi- half
hepat/o liver
hist/o tissue
holo- entire, complete
home/o sameness; unchanging; constant
hydr/o water
hyper- above; excessive
hypo- deficient; below; under; less than normal
-ia condition
-iac pertaining to
-iasis abnormal condition
-ic pertaining to
-ical pertaining to
-icle small
in- in; into; not
-in/e a substance; chemical, chemical compound
-ine pertaining to
infra- below; inferior; beneath
inter- between
VOCABULARY
Page 37
intra- within; into
-ion process
-ior pertaining to
ir- in
is/o same; equal
-ism process; condition
-itis inflammation
labi/o lip
lal/o speech
-lalia speech
lapar/o abdominal wall; abdominal
-lapse to slide; fall; sag
later/o side
-lepsy seizure
levo- left
lex/o word; phrase
lexia word; phrase
lingu/o tongue
-lipsis omit; fail
-logist specialist
log/o study
-logy study (process of)
-lysis breakdown; separation; destruction; loosening
-lytic to reduce; destroy; separate; breakdown
macro- large
mal- bad
-malacia softening
-mania obsessive preoccupation
medi/o middle
mega large
-megaly enlargement
meso- middle
meta- change; beyond
-meter measure
-metry process of measuring
VOCABULARY
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mi/o smaller; less
micro- small
mon/o one; single
multi- many
my/o muscle
myc/o fungus
mydr/o wide
necr/o death
neo- new
nephr/o kidney
neur/o nerve
noct/o night
nos/o disease
ocul/o eye
-oid resembling; derived from
-ole little; small
olig/o scanty
-oma tumor; mass; fluid collection
onc/o tumor
one mono; uni
-opia vision condition
-or one who
or/o mouth
orth/o straight
os opening; mouth
-ose full of; pertaining to
-osis condition (usually abnormal)
oste/o bone
-ous pertaining to
pale/o old
pali- recurrence; repetition
palp/o to touch gently
plapit/o flutter; throbbing
pan- all
par- other than; abnormal
VOCABULARY
Page 39
para- near; beside; abnormal; apart from; along the side of
-paresis weakness
path/o disease
-pathy disease; emotion
ped/o child; foot
-penia deficiency
per- through
peri- surrounding
phag/o eat; swallow
phas/o speech
-phasia speech
-phoresis carrying; transmission
physi/o nature; function
-plasia development; formation
-plasty surgical repair
-plegia paralysis
-pnea breathing
pneum/o lung; air; gas
poly- many; much
post- after; behind
pre- before; in front of
pro- before; forward
proxim/o near
pseudo- false
psych/o mind
-ptosis droop; sag; prolapse; protrude
py/o pus
quadri- four; square
quant- how much
quasi- to some degree; as if
re- back; again; backward
retro- behind; back; backward
rhe/o flow; current; stream
rhin/o nose
rot/o turn; revolve
VOCABULARY
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-rrhage bursting forth (of blood)
-rrhea flow; discharge
-sclerosis hardening
-scope instrument for visual examination
sect/o to cut
semi- half
-sepsis putrefaction
seps/o infection
sept/o partition
-sis state of; condition
somat/o body
-spasm sudden contraction of muscles
-stasis to stop; control, place
-stat device/instrument for keeping something stationary
-stenosis tightening; stricture
stomat/o mouth
-stomy new opening
sub- under or below
super- above; beyond
supra- above; upper
sym- together; with
syn- together; with
tachy- fast
-tension pressure
-therapy treatment
thorac/o chest
thromb/o clot
-tic pertaining to
-tomy process of cutting
trans- across; through
-trophy nourishment; development (condition of)
-ule little; small
ultra- beyond; excess
-um structure; tissue; thing
uni- one
VOCABULARY
Page 41
-us structure; thing
vascul/o vessel (blood)
ven/o vein
ven/i vein
-verse to turn
-ward in the direction of
-where location
-wise direction
with- together; united
-y condition; process
ABBREVIATIONS
Page 42
Abbreviations
• Billers and Coders need a list of approved abbreviations used by the Paramedics
and EMT’s in order to understand their documentation.
• As abbreviations are updated they need to be shared with the billing staff.
ABBREVIATIONS
Page 43
AAA abdominal aortic aneurysm
ABC airway, breathing, circulation
abd abdominal
AC antecubital (inside of the elbow)
a.c. before meals
ACL anterior cruciate ligament
ACLS advanced cardiac life support
ad lib at liberty (Example: "patient can be up ad lib.")
ADL activities of daily living
AEMT advanced level emergency medical technician
A-fib atrial fibrillation
AICD automatic implanted cardiac defibrillator
AKA also known as
AKA above the knee amputation
AMA against medical advice
AMI acute myocardial infarction
A/O alert and oriented (as in "A/O x 4)
A/P anterior/posterior
APRN Advanced Practice Registered Nurse
ASA aspirin
B Basic (as in: EMT-B)
BBB bundle branch block
b.i.d. twice a day
BKA below the knee amputation
BLS basic life support
BMI body mass index
BP or B/P blood pressure
bpm beats per minute
BS blood sugar
BSA body surface area
Ca cancer
CABG coronary artery bypass graph
CAD coronary artery disease
CAT (scan) computerized axial tomography
CBD complete blood count
ABBREVIATIONS
Page 44
C/C chief complaint
CCEMTP Certified Critical Care Emergency Medical Technician Paramedic
CHF congestive heart failure
CNM Certified Nurse Midwife
c with
cm centimeter
c-spine cervical spine
CMS circulation, movement, sensation
CNS central nervous system
C/O complaint of
COPD chronic obstructive pulmonary disease
CP cerebral palsy
CPAP continuous positive airway pressure
CPR cardio pulmonary resuscitation
CSW Clinical Social Worker
CT computed tomography
CTA clear to auscultation
CVA cerebrovascular accident (stroke)
D5W dextrose 5% in water
D50 dextrose 50%
DKA diabetes ketoacidosis
DM diabetes mellitus
DNR do not resuscitate
DOE dyspnea on exertion
DO Doctor of Osteopathy
DOA dead on arrival
d/t due to
DVT deep vein thrombosis
dx diagnosis
ECG electrocardiograph
EJ external jugular (vein)
EKG electrocardiograph
EMR Emergency Medical Responder
EMT Emergency Medical Technician
EMT-P Emergency Medical Technician - Paramedic
ABBREVIATIONS
Page 45
ePCR electronic patient care report
ESRD end stage renal disease
ESRF end stage renal failure
ETA estimated time of arrival
ETOH alcohol
ET / ETT endotracheal tube
FBS finger stick blood sugar
FBS fasting blood sugar
FHT fetal heart tones
Fx fracture
G-P gravida / Para
GSW gunshot wound
gtt drop / drops
Gm gram
HA head ache
HEENT head, eyes, ears, nose, throat
H&P history and physical
H/O history of
HPI history of present illness
h.s. at bedtime
hx history
HTN hypertension
ICF intermediate care facility
ICP intracranial pressure
IDDN insulin dependant diabetes mellitus
IM intramuscular
IV intravenous
IVP IV Push
K potassium
KCl potassium chloride
Kg kilogram
L liter
L&D labor and delivery
LE law enforcement
LLE left lower extremity
ABBREVIATIONS
Page 46
LLL left lower lobe (of lung)
LLQ left lower quadrant (abdominal)
LUQ left upper quadrant (abdominal)
LMP last menstrual period
LPN Licensed Practical Nurse
MCL medial collateral ligament
MD Medical Doctor
ME Medical Examiner
Mg milligrams
MI myocardial infarction ("heart attack")
Ml milliliters
MRI magnetic resonance imaging
MRSA methicillin resistant staph aureus
MS morphine sulfate
MVA motor vehicle accident
MVC motor vehicle crash
NC nasal cannula
NKA no known allergy
NKDA no known drug allergy
NRB non-rebreather (oxygen mask)
NS normal saline
NTG nitroglycerine
N/V nausea and vomiting
N/V/D nausea, vomiting, and diarrhea
Na sodium
NG nasogastric (tube)
NP Nurse Practioner
npo nothing by mouth
NRP Nationally Registered Paramedic
NSR normal sinus rhythm
NSTEMI Non-elevated ST segment myocardial infarction
O2 oxygen
OD overdose
O.D right eye
O.S. left eye
ABBREVIATIONS
Page 47
O.U. both eyes
OT occupational therapy
OTC over the counter
ORIF open reduction and internal fixation (such as for a hip fx)
P Paramedic
P pulse
p after
PA Physician Assistant
PCR patient care report
PD police department
PE pulmonary embolus
PE physical exam
PEG percutaneous endoscopic gastrostomy (PEG tube)
PERLA pupils equal, reactive to light and accommodation
PERRLA pupils equal, round, reactive to light and accommodation
PICC peripherally inserted central catheter (IV line)
PMH past medical history
PMS pulse, movement, sensation
PPE personal protective equipment
prn as needed
pt patient
PT physical therapy
PTA prior to arrival
PTAA prior to ambulance arrival
q every
q.d each day
q.i.d. four times a day
q2h every two hours
RLE right lower extremity
RLL right lower lobe (of lung)
ROM range of motion
ROM rupture of membranes (pregnancy related)
RN Registered Nurse
R/O rule out
RLQ right lower quadrant (abdomen)
ABBREVIATIONS
Page 48
RUQ right upper quadrant (abdomen)
Rx prescription
s without
s/p status post
SNF skilled nursing facility
SNT soft, nontender
SOA shortness of air
SOB shortness of breath
SQ subcutaneous
STEMI ST elevation myocardial infarction
Sx symptoms
s/sx signs and symptoms
sz seizure
T temperature
t.i.d. three times a day
TKO to keep open (Example: "IV NS TKO")
Tx treatment
UA urinary analysis
US ultrasound
UTI urinary tract infection
V-fib ventricular fibrillation
V-Tach ventricular tachycardia
WNL within normal limits
wt weight
y/o year old (Example: "42 y/o female...")
UNDERSTANDING LAB VALUES AND VITALS
Page 49
Understanding Lab Values and Vitals
• A lab value or vital sign reported as lower or higher than a normal range may not
necessarily indicate a disorder, but:
o It can help support medical necessity; therefore, a biller/coder needs to
understand the normal values.
o It can tell the story of what is going on with the patient and help to define
their disease process.
o Provide information to help a biller/coder to decide the appropriate
diagnosis.
Blood Pressure
• When measuring blood pressure, your doctor or nurse will use a stethoscope to
listen to the blood moving through an artery.
• The cuff is inflated to a pressure that’s known to be higher than your systolic blood
pressure. As the cuff deflates, the first sound heard through the stethoscope is the
systolic blood pressure. It sounds like a whooshing noise. When this noise goes
away, that indicates the diastolic blood pressure.
• The systolic blood pressure number is always said first, and then the diastolic blood
pressure number is given. For example, your blood pressure may be read as "120
over 80" or written as 120/80.
• Blood pressure is measured in millimeters of mercury (mm Hg).
http://www.webmd.com/hypertension-high-blood-pressure/guide/diastolic-and-systolic-blood-pressure-know-your-numbers
UNDERSTANDING LAB VALUES AND VITALS
Page 50
What can the Blood Pressure tell a biller/coder?
Pulse Ox
A procedure used to measure the oxygen level (or oxygen saturation) in the blood. It is
considered to be a noninvasive, painless, general indicator of oxygen delivery to the
peripheral tissues (such as the finger, earlobe, or nose).
What can the Pulse Oximetry tell a biller/coder?
Blood Glucose Test • Is a way of testing the concentration of glucose in the blood (glycemia).
• A blood glucose test is performed by piercing the skin (typically, on the finger) to
draw blood, then applying the blood to a chemically active disposable 'test-strip'.
http://www.hopkinsmedicine.org/healthlibrary/test_procedures/pulmonary/oximetry_92,P07754/
UNDERSTANDING LAB VALUES AND VITALS
Page 51
• Different manufacturers use different technology, but most systems measure an
electrical characteristic, and use this to determine the glucose level in the blood.
• The test is usually referred to as capillary blood glucose.
What can the Blood Glucose Test tell a biller/coder?
ETCO2(End-Tidal CO2)
• The level of carbon dioxide released at the end of an exhaled breath (expiration).
• Carbon dioxide (CO2) reflects cardiac output and pulmonary blood flow as the gas
is transported by the venous system to the heart and then pumped to the lungs.
• Carbon dioxide concentration reaches a maximum at the end of exhalation.
• When carbon dioxide diffuses out of the lungs into the exhaled air, the partial
pressure or maximal concentration of the gas at the end of exhalation can be
measured.
What can the ETCO2 Test tell a biller/coder?
• A high ETCO2 reading in a patient with altered mental status or severe difficulty
breathing may indicate hypoventilation and a possible need for the patient to be
intubated.
• Low ETCO2 readings on patients may indicate hyperventilation.
https://en.wikipedia.org/wiki/Blood_glucose_monitoring
UNDERSTANDING LAB VALUES AND VITALS
Page 52
https://en.wikipedia.org/wiki/Capnography
Heart Rate
The heart rate, or pulse, is the number of times your heart beats per minute.
What can the Heart Rate tell a biller/coder?
https://en.wikipedia.org/wiki/Heart_rate
Hemoglobin
• Protein in red blood cells that carries oxygen
• Each red blood cell contains several hundred thousand hemoglobin molecules,
which transport oxygen.
Normal values:
Male: 13.8 to 17.2 gm/dL
Female: 12.1 to 15.1 gm/dL
Note: gm/dL = grams per deciliter
What can the Hemoglobin Test tell a biller/coder?
• Low hemoglobin could indicate anemia.
o Signs and Symptoms: pale skin, weakness, SOB, fainting, palpitations, chest
pain, and restless leg syndrome
UNDERSTANDING LAB VALUES AND VITALS
Page 53
• High hemoglobin could indicate a lung disease, bone
marrow disorders, overdose or inappropriate use of
the drug epoetin alpha.
Hematocrit (Hct)
• Number and size of red blood cells • Performed due to anemia, diet deficiency, and
leukemia.
Normal values: Male: 40.7-50.3% Female: 36.1-44.3%
What can the Hematocrit Test tell a biller/coder?
• Low hematocrit could indicate anemia, bleeding, leukemia, malnutrition, iron,
folate, B12 & B6 deficiency, or over-hydration.
• High hematocrit could be a sign of right-sided heart failure, dehydration, hypoxia,
pulmonary fibrosis, bone marrow disease and congenital heart disease.
MEDICATIONS
Page 54
Medications
Medication can help a biller/coder to recognize a patient that has a certain
condition, such insulin for diabetes, or a patient on tamoxifen for breast cancer.
Billing learns important information from medications taken by the patients and
can:
o Help a biller/coder to look for certain conditions and procedures.
o Understand some of the signs and symptoms.
Important Terms
Interosseous-Percutaneous placement of an intravenous catheter into a marrow
cavity provides an alternative route for the administration of fluids and medication
when peripheral blood vessels are collapsed or inaccessible. For EMS purposes, the
proximal tibia or the humerus are the most frequently used sites.
Intramuscular-Within a muscle.
Intranasal-Taken by Nose.
NTG-Used for the prophylaxis and treatment of angina pectoris, the treatment of
congestive heart failure and myocardial infarction
Oral-Taken by mouth.
Subcutaneous-Located, found, or placed just beneath the skin; hypodermic.
Sublingual-Refers to the pharmacological route of administration by which drugs
diffuse into the blood through tissues under the tongue.
Intravenous-Is the infusion of liquid substances directly into a vein
IV Bolus-A large volume of fluid or dose of a drug given intravenously and rapidly
at one time.
IV Drip or Infusion-It is commonly referred to as a drip because many systems of
administration employ a drip chamber, which prevents air from entering the blood
stream (air embolism), and allows an estimation of flow rate.
MEDICATIONS
Page 55
IV Push -Method of quickly injecting medications into a vein.
Number of Dosages-The amount of a therapeutic agent administered.
Routes-Is the path by which a drug, fluid, poison, or other substance is taken into
the body.
SYMPTOMS, SIGNS AND ABNORMAL CLINICAL LABORATORY FINDINGS
Page 56
Symptoms, Signs and Abnormal Clinical Laboratory Findings
In medicine a symptom is generally subjective while a sign is objective.
SIGN
Is a disease observed by the doctor, nurse, family members and the patient, such as blood
in the stool, a skin rash.
SYMPTOM
However, stomach, lower-back pain, fatigue, for example, can only be detected or sensed
by the patient - others only know about it if the patient tells them.
Light headache - this can only be a symptom.
• A light headache can only be a symptom because it is only ever detected by the patient.
High blood sugar - this can only be a sign
• High blood sugar can only be a sign because the patient cannot detect it; it can only be measured in a medical laboratory.
ICD-10-CM
1. Consist of codes for cases when more specific diagnosis cannot be made even after
all the facts bearing the case have been investigated; and
2. Signs and symptoms existing at the time of the encounter that proved to be the
reason for the encounter.
Many signs and symptoms are grouped by body part or relevant group.
In ambulance transports, code the sign and symptom diagnosis that is the
reason for transport and use any additional codes to support the need for the
transport.
SYMPTOMS, SIGNS AND ABNORMAL CLINICAL LABORATORY FINDINGS
Page 57
In ICD-10 coding guidelines, it is acceptable to use signs and symptoms when a
definitive diagnosis cannot be determined, which often times is the case with
emergency transports.
If signs and symptoms are used, it’s a good rule to document in the narrative
box 19 on the CMS claim form.
If a more precise diagnosis is available, refer to your payor guidelines when
coding.
PAIN
Pain is the reason for the transport. Acute onset or bed-confining.
Pain is severity of 7–10 on 10-point severity scale despite pharmacologic
intervention.
Patient needs specialized handling to be moved.
Other emergency conditions are present or reasonably suspected.
Signs of other life- or limb-threatening conditions are present.
Associated cardiopulmonary, neurologic, or peripheral vascular signs and
symptoms are present.
SYMPTOMS, SIGNS AND ABNORMAL CLINICAL LABORATORY FINDINGS
Page 58
ICD-10 Code Code Description
R52 Pain unspecified
FEVER
Significantly high fever unresponsive to pharmacologic intervention.
Adult >102 F after pharmacologic intervention.
Child > 104 F after pharmacologic intervention.
ICD-10 Code Code Description
R50.81 Fever presenting with other conditions
R50.82 Post procedural fever
R50.83 Post vaccination fever
R50.9 Fever unspecified
HYPOTHERMIA
A disorder characterized by an abnormally low body temperature.
Treatment is required when the body temperature is 35c (95f) or below.
Abnormal low body temperature
Abnormally low body temperature. Treatment is required when the body
temperature is 35c (95f) or below. Symptoms include decreased mental function,
lethargy, and disorientation.
ICD-10 Code Code Description
R68.0 Hypothermia not associated with weather
SYMPTOMS, SIGNS AND ABNORMAL CLINICAL LABORATORY FINDINGS
Page 59
OTHER MALAISE AND FATIGUE
A disorder characterized by a feeling of general discomfort or uneasiness, an out-of-
sorts feeling.
A feeling of general discomfort or uneasiness, an out-of-sorts feeling.
A mental disorder characterized by chronic fatigue and concomitant physiologic
symptoms.
Malaise: a vague feeling of physical discomfort or apprehension.
The property of lacking physical or mental strength; liability to failure under pressure
or stress or strain.
ICD-10 Code Code Description
R53.81 Other malaise
R53.83 Other fatigue
R53.1 Weakness
SYMPTOMS, SIGNS AND ABNORMAL CLINICAL LABORATORY FINDINGS
Page 60
OTHER GENERAL SYMPTOMS
ABNORMALITIES OF MOVEMENT
Disorders characterized by lack of coordination of muscle movements resulting in the
impairment or inability to perform voluntary activities. Impairment of the ability to
coordinate the movements required for normal ambulation (walking), which may result
from impairments of motor function or sensory feedback.
ICD-10 Code Code Description
R26.0 Ataxia gait
SYMPTOMS, SIGNS AND ABNORMAL CLINICAL LABORATORY FINDINGS
Page 61
R26.1 Paralytic gait
R26.89 Other abnormalities of gait and mobility
R26.9 Unspecified abnormalities of gait and mobility
R27.0 Ataxia, unspecified
R27.8 Other lack of coordination
R27.9 Unspecified lack of coordination
R29.6 Repeated falls
GREAT RESOURCE
Page 62
Great Resource
http://www.roadto10.org/action-plan/phase-2-train/common-codes-other/
Many of the examples were taken from the CMS website.
CERTAIN INFECTIOUS AND PARASITIC DISEASES
Page 63
Certain Infectious and Parasitic Diseases
Infections are grouped by Infections.
o Sexual
o Viral Hepatitis
o Many of the codes have been expanded to reflect manifestations of the
disease; and
o Septicemia is replaced with Sepsis, ALL bloodstream infections are classified
as Sepsis.
WHAT IS SEPSIS?
It is a life threatening system bloodstream infection, originating in the:
Urinary Tract
Lungs
GI Tract
Surgical Wound
DISEASES OF BLOOD, BLOOD-FORMING ORGANS OR HEMORRHAGE
Page 64
Diseases of Blood, Blood-Forming Organs or Hemorrhage
ANEMIA
Grouped by conditions
• Nutritional Anemias
• Hemolytic Anemias
• Aplastic and Other Anemias and Other Bone Marrow Failure Syndromes.
• Coagulation Defects, Purpura and Other Hemorrhagic Conditions
• Other Disorders of Blood Forming Organs.
• Intraoperative and post procedural complications of the spleen.
• Certain disorders involving the immune system.
HEMORRHAGE
Potentially life-threatening hemorrhage
Uncontrolled bleeding
Signs of shock and active severe bleeding (quantity identified)
Ongoing or recent bleeding, with potential of immediate re-bleeding
ICD-10 Code Code Description
In ICD-9-CM, 459.0-Hemorrhage could be found in the Disease of the Circulatory System
DISEASES OF BLOOD, BLOOD-FORMING ORGANS OR HEMORRHAGE
Page 65
R58 Hemorrhage, Not Elsewhere Classified
ENDOCRINE, NUTRITIONAL AND METABOLIC DISEASES
Page 66
Endocrine, Nutritional and Metabolic Diseases
DIABETES MELLITUS
• Increased level of specificity
• The diabetes mellitus codes are combination codes that includes:
o The type of body system effected.
o The complications affecting the body system.
Diabetes Mellitus is a disorder in which blood sugar (glucose) levels are abnormally
high because the body does not produce enough insulin.
Insulin, a hormone released from the pancreas, controls the amount of sugar in the
blood. It allows sugar to move from the blood into the cells. Once inside the cells,
sugar is converted to energy.
Types:
Type 1
• Formerly called insulin-dependent or juvenile-onset diabetes.
• More than 90% of the insulin-producing cells of the pancreas are permanently
destroyed.
• The body does not produce enough insulin.
• Most people with type I diabetes develop the disease before age 30.
Type 2
• Formerly called non-insulin dependent diabetes or adult-onset diabetes.
• The pancreas continues to produce insulin, sometimes even at higher than
normal levels.
• Body develops resistance to the effects of insulin, so there is not enough
insulin to meet the body’s needs.
• May occur in children and adolescents, but usually begins in people older than
30 and becomes progressively more common with age.
ENDOCRINE, NUTRITIONAL AND METABOLIC DISEASES
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Drug or Chemical Induced
Due to Underlying Condition
Secondary Diabetes
Gestational
No longer classified as controlled/uncontrolled
• Only classified as diabetes with Hyperglycemia or Hypoglycemia.
• Defined by out of control, inadequate control, or poorly controlled.
• If Hypoglycemia it’s coded separately, or
• Hyperglycemia maybe coded without diabetes.
Complications:
• What if any other body systems are affected by the diabetes condition? I.e. foot
ulcer.
Treatment:
• Is the patient on Insulin?
CODING CHANGES
There are five (5) Diabetes Mellitus categories in the ICD-10-CM. They are:
• E08 Diabetes Mellitus due to an underlying condition
• E09 Drug or chemical induced diabetes mellitus
• E10 Type I diabetes mellitus
• E11 Type 2 diabetes mellitus
• E13 Other specified diabetes mellitus
Diabetes mellitus codes expanded to include the classification of the diabetes and the
manifestation.
ENDOCRINE, NUTRITIONAL AND METABOLIC DISEASES
Page 68
ICD-10 Code Code Description
E08.00 Diabetes mellitus due to underlying condition with hyperosmolarity without nonketotic hyperglycemic-hyperosmolar coma (NKHHC)
E08.01 Diabetes mellitus due to underlying condition with hyperosmolarity with coma
E08.10 Diabetes mellitus due to underlying condition with ketoacidosis without coma
E08.11 Diabetes mellitus due to underlying condition with ketoacidosis with coma
E08.21 Diabetes mellitus due to underlying condition with diabetic nephropathy
E08.22 Diabetes mellitus due to underlying condition with diabetic chronic kidney disease
E08.29 Diabetes mellitus due to underlying condition with other diabetic kidney complication
E08.311 Diabetes mellitus due to underlying condition with unspecified diabetic retinopathy with macular edema
E08.319 Diabetes mellitus due to underlying condition with unspecified diabetic retinopathy without macular edema
E08.321 Diabetes mellitus due to underlying condition with mild nonproliferative diabetic retinopathy with macular edema
E08.329 Diabetes mellitus due to underlying condition with mild nonproliferative diabetic retinopathy without macular edema
E08.331 Diabetes mellitus due to underlying condition with moderate nonproliferative diabetic retinopathy with macular edema
E08.339 Diabetes mellitus due to underlying condition with moderate nonproliferative diabetic retinopathy without macular edema
E08.341 Diabetes mellitus due to underlying condition with severe nonproliferative diabetic retinopathy with macular edema
E08.349 Diabetes mellitus due to underlying condition with severe nonproliferative diabetic retinopathy without macular edema
E08.351 Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy with macular edema
E08.359 Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy without macular edema
E08.36 Diabetes mellitus due to underlying condition with diabetic cataract
ENDOCRINE, NUTRITIONAL AND METABOLIC DISEASES
Page 69
E08.39 Diabetes mellitus due to underlying condition with other diabetic ophthalmic complication
E08.40 Diabetes mellitus due to underlying condition with diabetic neuropathy, unspecified
E08.41 Diabetes mellitus due to underlying condition with diabetic mononeuropathy
E08.42 Diabetes mellitus due to underlying condition with diabetic polyneuropathy
E08.43 Diabetes mellitus due to underlying condition with diabetic autonomic (poly)neuropathy
E08.44 Diabetes mellitus due to underlying condition with diabetic amyotrophy
E08.49 Diabetes mellitus due to underlying condition with other diabetic neurological complication
E08.51 Diabetes mellitus due to underlying condition with diabetic peripheral angiopathy without gangrene
E08.52 Diabetes mellitus due to underlying condition with diabetic peripheral angiopathy with gangrene
E08.59 Diabetes mellitus due to underlying condition with other circulatory complications
E08.610 Diabetes mellitus due to underlying condition with diabetic neuropathic arthropathy
E08.618 Diabetes mellitus due to underlying condition with other diabetic arthropathy
E08.620 Diabetes mellitus due to underlying condition with diabetic dermatitis
E08.621 Diabetes mellitus due to underlying condition with foot ulcer
E08.622 Diabetes mellitus due to underlying condition with other skin ulcer
E08.628 Diabetes mellitus due to underlying condition with other skin complications
E08.630 Diabetes mellitus due to underlying condition with periodontal disease
E08.638 Diabetes mellitus due to underlying condition with other oral complications
E08.641 Diabetes mellitus due to underlying condition with hypoglycemia with coma
ENDOCRINE, NUTRITIONAL AND METABOLIC DISEASES
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E08.649 Diabetes mellitus due to underlying condition with hypoglycemia without coma
E08.65 Diabetes mellitus due to underlying condition with hyperglycemia
E08.69 Diabetes mellitus due to underlying condition with other specified complication
E08.8 Diabetes mellitus due to underlying condition with unspecified complications
E08.9 Diabetes mellitus due to underlying condition without complications
E09.00 Drug or chemical induced diabetes mellitus with hyperosmolarity without nonketotic hyperglycemic-hyperosmolar coma (NKHHC)
E09.01 Drug or chemical induced diabetes mellitus with hyperosmolarity with coma
E09.10 Drug or chemical induced diabetes mellitus with ketoacidosis without coma
E09.11 Drug or chemical induced diabetes mellitus with ketoacidosis with coma
E09.21 Drug or chemical induced diabetes mellitus with diabetic nephropathy
E09.22 Drug or chemical induced diabetes mellitus with diabetic chronic kidney disease
E09.29 Drug or chemical induced diabetes mellitus with other diabetic kidney complication
E09.311 Drug or chemical induced diabetes mellitus with unspecified diabetic retinopathy with macular edema
E09.319 Drug or chemical induced diabetes mellitus with unspecified diabetic retinopathy without macular edema
E09.321 Drug or chemical induced diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema
E09.329 Drug or chemical induced diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema
E09.331 Drug or chemical induced diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema
E09.339 Drug or chemical induced diabetes mellitus with moderate nonproliferative diabetic retinopathy without macular edema
E09.341 Drug or chemical induced diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema
ENDOCRINE, NUTRITIONAL AND METABOLIC DISEASES
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E09.349 Drug or chemical induced diabetes mellitus with severe nonproliferative diabetic retinopathy without macular edema
E09.351 Drug or chemical induced diabetes mellitus with proliferative diabetic retinopathy with macular edema
E09.359 Drug or chemical induced diabetes mellitus with proliferative diabetic retinopathy without macular edema
E09.36 Drug or chemical induced diabetes mellitus with diabetic cataract
E09.39 Drug or chemical induced diabetes mellitus with other diabetic ophthalmic complication
E09.40 Drug or chemical induced diabetes mellitus with neurological complications with diabetic neuropathy, unspecified
E09.41 Drug or chemical induced diabetes mellitus with neurological complications with diabetic mononeuropathy
E09.42 Drug or chemical induced diabetes mellitus with neurological complications with diabetic polyneuropathy
E09.43 Drug or chemical induced diabetes mellitus with neurological complications with diabetic autonomic (poly)neuropathy
E09.44 Drug or chemical induced diabetes mellitus with neurological complications with diabetic amyotrophy
E09.49 Drug or chemical induced diabetes mellitus with neurological complications with other diabetic neurological complication
E09.51 Drug or chemical induced diabetes mellitus with diabetic peripheral angiopathy without gangrene
E09.52 Drug or chemical induced diabetes mellitus with diabetic peripheral angiopathy with gangrene
E09.59 Drug or chemical induced diabetes mellitus with other circulatory complications
E09.610 Drug or chemical induced diabetes mellitus with diabetic neuropathic arthropathy
E09.618 Drug or chemical induced diabetes mellitus with other diabetic arthropathy
E09.620 Drug or chemical induced diabetes mellitus with diabetic dermatitis
E09.621 Drug or chemical induced diabetes mellitus with foot ulcer
E09.622 Drug or chemical induced diabetes mellitus with other skin ulcer
ENDOCRINE, NUTRITIONAL AND METABOLIC DISEASES
Page 72
E09.628 Drug or chemical induced diabetes mellitus with other skin complications
E09.630 Drug or chemical induced diabetes mellitus with periodontal disease
E09.638 Drug or chemical induced diabetes mellitus with other oral complications
E09.641 Drug or chemical induced diabetes mellitus with hypoglycemia with coma
E09.649 Drug or chemical induced diabetes mellitus with hypoglycemia without coma
E09.65 Drug or chemical induced diabetes mellitus with hyperglycemia
E09.69 Drug or chemical induced diabetes mellitus with other specified complication
E09.8 Drug or chemical induced diabetes mellitus with unspecified complications
E09.9 Drug or chemical induced diabetes mellitus without complications
E10.10 Type 1 diabetes mellitus with ketoacidosis without coma
E10.11 Type 1 diabetes mellitus with ketoacidosis with coma
E10.21 Type 1 diabetes mellitus with diabetic nephropathy
E10.22 Type 1 diabetes mellitus with diabetic chronic kidney disease
E10.29 Type 1 diabetes mellitus with other diabetic kidney complication
E10.311 Type 1 diabetes mellitus with unspecified diabetic retinopathy with macular edema
E10.319 Type 1 diabetes mellitus with unspecified diabetic retinopathy without macular edema
E10.321 Type 1 diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema
E10.329 Type 1 diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema
E10.331 Type 1 diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema
ENDOCRINE, NUTRITIONAL AND METABOLIC DISEASES
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E10.339 Type 1 diabetes mellitus with moderate nonproliferative diabetic retinopathy without macular edema
E10.341 Type 1 diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema
E10.349 Type 1 diabetes mellitus with severe nonproliferative diabetic retinopathy without macular edema
E10.351 Type 1 diabetes mellitus with proliferative diabetic retinopathy with macular edema
E10.359 Type 1 diabetes mellitus with proliferative diabetic retinopathy without macular edema
E10.36 Type 1 diabetes mellitus with diabetic cataract
E10.39 Type 1 diabetes mellitus with other diabetic ophthalmic complication
E10.40 Type 1 diabetes mellitus with diabetic neuropathy, unspecified
E10.41 Type 1 diabetes mellitus with diabetic mononeuropathy
E10.42 Type 1 diabetes mellitus with diabetic polyneuropathy
E10.43 Type 1 diabetes mellitus with diabetic autonomic (poly)neuropathy
E10.44 Type 1 diabetes mellitus with diabetic amyotrophy
E10.49 Type 1 diabetes mellitus with other diabetic neurological complication
E10.51 Type 1 diabetes mellitus with diabetic peripheral angiopathy without gangrene
E10.52 Type 1 diabetes mellitus with diabetic peripheral angiopathy with gangrene
E10.59 Type 1 diabetes mellitus with other circulatory complications
E10.610 Type 1 diabetes mellitus with diabetic neuropathic arthropathy
E10.618 Type 1 diabetes mellitus with other diabetic arthropathy
E10.620 Type 1 diabetes mellitus with diabetic dermatitis
ENDOCRINE, NUTRITIONAL AND METABOLIC DISEASES
Page 74
E10.621 Type 1 diabetes mellitus with foot ulcer
E10.622 Type 1 diabetes mellitus with other skin ulcer
E10.628 Type 1 diabetes mellitus with other skin complications
E10.630 Type 1 diabetes mellitus with periodontal disease
E10.638 Type 1 diabetes mellitus with other oral complications
E10.641 Type 1 diabetes mellitus with hypoglycemia with coma
E10.649 Type 1 diabetes mellitus with hypoglycemia without coma
E10.65 Type 1 diabetes mellitus with hyperglycemia
E10.69 Type 1 diabetes mellitus with other specified complication
E10.8 Type 1 diabetes mellitus with unspecified complications
E10.9 Type 1 diabetes mellitus without complications
E11.00 Type 2 diabetes mellitus with hyperosmolarity without nonketotic hyperglycemic-hyperosmolar coma (NKHHC)
E11.01 Type 2 diabetes mellitus with hyperosmolarity with coma
E11.21 Type 2 diabetes mellitus with diabetic nephropathy
E11.22 Type 2 diabetes mellitus with diabetic chronic kidney disease
E11.29 Type 2 diabetes mellitus with other diabetic kidney complication
E11.311 Type 2 diabetes mellitus with unspecified diabetic retinopathy with macular edema
E11.319 Type 2 diabetes mellitus with unspecified diabetic retinopathy without macular edema
E11.321 Type 2 diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema
ENDOCRINE, NUTRITIONAL AND METABOLIC DISEASES
Page 75
E11.329 Type 2 diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema
E11.331 Type 2 diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema
E11.339 Type 2 diabetes mellitus with moderate nonproliferative diabetic retinopathy without macular edema
E11.341 Type 2 diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema
E11.349 Type 2 diabetes mellitus with severe nonproliferative diabetic retinopathy without macular edema
E11.351 Type 2 diabetes mellitus with proliferative diabetic retinopathy with macular edema
E11.359 Type 2 diabetes mellitus with proliferative diabetic retinopathy without macular edema
E11.36 Type 2 diabetes mellitus with diabetic cataract
E11.39 Type 2 diabetes mellitus with other diabetic ophthalmic complication
E11.40 Type 2 diabetes mellitus with diabetic neuropathy, unspecified
E11.41 Type 2 diabetes mellitus with diabetic mononeuropathy
E11.42 Type 2 diabetes mellitus with diabetic polyneuropathy
E11.43 Type 2 diabetes mellitus with diabetic autonomic (poly)neuropathy
E11.44 Type 2 diabetes mellitus with diabetic amyotrophy
E11.49 Type 2 diabetes mellitus with other diabetic neurological complication
E11.51 Type 2 diabetes mellitus with diabetic peripheral angiopathy without gangrene
E11.52 Type 2 diabetes mellitus with diabetic peripheral angiopathy with gangrene
E11.59 Type 2 diabetes mellitus with other circulatory complications
E11.610 Type 2 diabetes mellitus with diabetic neuropathic arthropathy
ENDOCRINE, NUTRITIONAL AND METABOLIC DISEASES
Page 76
E11.618 Type 2 diabetes mellitus with other diabetic arthropathy
E11.620 Type 2 diabetes mellitus with diabetic dermatitis
E11.621 Type 2 diabetes mellitus with foot ulcer
E11.622 Type 2 diabetes mellitus with other skin ulcer
E11.628 Type 2 diabetes mellitus with other skin complications
E11.630 Type 2 diabetes mellitus with periodontal disease
E11.638 Type 2 diabetes mellitus with other oral complications
E11.641 Type 2 diabetes mellitus with hypoglycemia with coma
E11.649 Type 2 diabetes mellitus with hypoglycemia without coma
E11.65 Type 2 diabetes mellitus with hyperglycemia
E11.69 Type 2 diabetes mellitus with other specified complication
E11.8 Type 2 diabetes mellitus with unspecified complications
E11.9 Type 2 diabetes mellitus without complications
E13.00 Other specified diabetes mellitus with hyperosmolarity without nonketotic hyperglycemic-hyperosmolar coma (NKHHC)
E13.01 Other specified diabetes mellitus with hyperosmolarity with coma
E13.10 Other specified diabetes mellitus with ketoacidosis without coma
E13.11 Other specified diabetes mellitus with ketoacidosis with coma
E13.21 Other specified diabetes mellitus with diabetic nephropathy
E13.22 Other specified diabetes mellitus with diabetic chronic kidney disease
ENDOCRINE, NUTRITIONAL AND METABOLIC DISEASES
Page 77
E13.29 Other specified diabetes mellitus with other diabetic kidney complication
E13.311 Other specified diabetes mellitus with unspecified diabetic retinopathy with macular edema
E13.319 Other specified diabetes mellitus with unspecified diabetic retinopathy without macular edema
E13.321 Other specified diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema
E13.329 Other specified diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema
E13.331 Other specified diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema
E13.339 Other specified diabetes mellitus with moderate nonproliferative diabetic retinopathy without macular edema
E13.341 Other specified diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema
E13.349 Other specified diabetes mellitus with severe nonproliferative diabetic retinopathy without macular edema
E13.351 Other specified diabetes mellitus with proliferative diabetic retinopathy with macular edema
E13.359 Other specified diabetes mellitus with proliferative diabetic retinopathy without macular edema
E13.36 Other specified diabetes mellitus with diabetic cataract
E13.39 Other specified diabetes mellitus with other diabetic ophthalmic complication
E13.40 Other specified diabetes mellitus with diabetic neuropathy, unspecified
E13.41 Other specified diabetes mellitus with diabetic mononeuropathy
E13.42 Other specified diabetes mellitus with diabetic polyneuropathy
E13.43 Other specified diabetes mellitus with diabetic autonomic (poly)neuropathy
E13.44 Other specified diabetes mellitus with diabetic amyotrophy
E13.49 Other specified diabetes mellitus with other diabetic neurological complication
ENDOCRINE, NUTRITIONAL AND METABOLIC DISEASES
Page 78
E13.51 Other specified diabetes mellitus with diabetic peripheral angiopathy without gangrene
E13.52 Other specified diabetes mellitus with diabetic peripheral angiopathy with gangrene
E13.59 Other specified diabetes mellitus with other circulatory complications
E13.610 Other specified diabetes mellitus with diabetic neuropathic arthropathy
E13.618 Other specified diabetes mellitus with other diabetic arthropathy
E13.620 Other specified diabetes mellitus with diabetic dermatitis
E13.621 Other specified diabetes mellitus with foot ulcer
E13.622 Other specified diabetes mellitus with other skin ulcer
E13.628 Other specified diabetes mellitus with other skin complications
E13.630 Other specified diabetes mellitus with periodontal disease
E13.638 Other specified diabetes mellitus with other oral complications
E13.641 Other specified diabetes mellitus with hypoglycemia with coma
E13.649 Other specified diabetes mellitus with hypoglycemia without coma
E13.65 Other specified diabetes mellitus with hyperglycemia
E13.69 Other specified diabetes mellitus with other specified complication
E13.8 Other specified diabetes mellitus with unspecified complications
E13.9 Other specified diabetes mellitus without complications
E16.1 Other hypoglycemia
E16.2 Hypoglycemia, unspecified
ENDOCRINE, NUTRITIONAL AND METABOLIC DISEASES
Page 79
O24.011 Pre-existing diabetes mellitus, type 1, in pregnancy, first trimester
O24.012 Pre-existing diabetes mellitus, type 1, in pregnancy, second trimester
O24.013 Pre-existing diabetes mellitus, type 1, in pregnancy, third trimester
O24.019 Pre-existing diabetes mellitus, type 1, in pregnancy, unspecified trimester
O24.02 Pre-existing diabetes mellitus, type 1, in childbirth
O24.03 Pre-existing diabetes mellitus, type 1, in the puerperium
O24.111 Pre-existing diabetes mellitus, type 2, in pregnancy, first trimester
O24.112 Pre-existing diabetes mellitus, type 2, in pregnancy, second trimester
O24.113 Pre-existing diabetes mellitus, type 2, in pregnancy, third trimester
O24.119 Pre-existing diabetes mellitus, type 2, in pregnancy, unspecified trimester
O24.12 Pre-existing diabetes mellitus, type 2, in childbirth
O24.13 Pre-existing diabetes mellitus, type 2, in the puerperium
O24.311 Unspecified pre-existing diabetes mellitus in pregnancy, first trimester
O24.312 Unspecified pre-existing diabetes mellitus in pregnancy, second trimester
O24.313 Unspecified pre-existing diabetes mellitus in pregnancy, third trimester
O24.319 Unspecified pre-existing diabetes mellitus in pregnancy, unspecified trimester
O24.410 Gestational diabetes mellitus in pregnancy, diet controlled
O24.414 Gestational diabetes mellitus in pregnancy, insulin controlled
O24.419 Gestational diabetes mellitus in pregnancy, unspecified control
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O24.420 Gestational diabetes mellitus in childbirth, diet controlled
O24.424 Gestational diabetes mellitus in childbirth, insulin controlled
O24.429 Gestational diabetes mellitus in childbirth, unspecified control
O24.430 Gestational diabetes mellitus in the puerperium, diet controlled
O24.434 Gestational diabetes mellitus in the puerperium, insulin controlled
O24.439 Gestational diabetes mellitus in the puerperium, unspecified control
O24.811 Other pre-existing diabetes mellitus in pregnancy, first trimester
O24.812 Other pre-existing diabetes mellitus in pregnancy, second trimester
O24.813 Other pre-existing diabetes mellitus in pregnancy, third trimester
O24.819 Other pre-existing diabetes mellitus in pregnancy, unspecified trimester
O24.82 Other pre-existing diabetes mellitus in childbirth
O24.83 Other pre-existing diabetes mellitus in the puerperium
O24.911 Unspecified diabetes mellitus in pregnancy, first trimester
O24.912 Unspecified diabetes mellitus in pregnancy, second trimester
O24.913 Unspecified diabetes mellitus in pregnancy, third trimester
O24.919 Unspecified diabetes mellitus in pregnancy, unspecified trimester
O24.92 Unspecified diabetes mellitus in childbirth
O24.93 Unspecified diabetes mellitus in the puerperium
Z79.4 Long term (current) use of insulin
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Z86.31 Personal history of diabetic foot ulcer
Z86.32 Personal history of gestational diabetes
HYPERGLYCEMIA
• High blood glucose happens when the body has too little insulin or when the body
can’t use insulin properly.
• Symptoms :
• increased thirst
o fatigue
o nausea and vomiting
o dry mouth
o rapid heartbeat
ICD-10 Code Description
R73.0 Abnormal glucose
R73.09 Other Abnormal glucose
HYPOGLYCEMIA
• Abnormally low levels of sugar (glucose) in the blood, usually less than 70 mg/dl.
• Low levels of sugar in the blood interferes with the function of many organ systems.
The brain is particularly sensitive to low sugar levels, because sugar is the brain’s
major energy source.
• Symptoms:
o shakiness or nervousness
o fatigue
o sweating
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o hunger
o nausea
o irritability
o irregular or racing heartbeat
o difficulty speaking
o confusion
ICD-10 Code Description
E16.0 Drug induced hypoglycemia without coma
E16.1 Other hypoglycemia
E16.2 Hypoglycemia unspecified
HYPOGLYCEMIC COMA
• Life threatening complication that causes unconsciousness.
• Diabetes, with either dangerously high blood sugar or dangerously low blood sugar,
can lead to a diabetic coma.
ICD-10 Code Description
E15 Nondiabetic hypoglycemic coma, includes drug-induced insulin coma
in nondiabetic, includes hypoglycemic coma NOS
OBESITY
• Documentation should give the patient’s height/weight.
• Any special handling and/or equipment used or the use of extra manpower should
also be documented.
• BMI > 80 (Morbid Obesity)
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ICD-10 Code Description
E66.3 Overweight
E66.8 Other obesity
E66.9 Obesity unspecified
VOLUME DEPLETION
Depletion of total body water.
ICD-10 Code Description
E86 Volume depletion
E86.0 Dehydration
E86.9 Volume depletion unspecified
HYPOVOLEMIA
Depletion of blood volume. Could be caused due to internal bleeding from intestine or
stomach, external bleeding from injury or loss of blood volume and body fluid associated
with diarrhea, vomiting, dehydration or burns.
Signs and symptoms: edema and ascites
ICD-10 Code Description
E86.1 Hypovolemia (Depletion of volume of plasma
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DEHYDRATION
• Occurs when the body loses more water than it takes in.
• Vomiting, diarrhea, the use of diuretics, profuse sweating, and decreased
water intake can all lead to dehydration.
• Symptoms include
– thirst
– reduced sweating
– reduced skin elasticity
– reduced urine production
– and dry mouth
ICD-10 Code Description
E86.0 Dehydration
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Behavioral Health
BEHAVIORAL DOCUMENTATION
• Expressing active signs and/or symptoms of uncontrolled psychiatric condition or
acute substance withdrawal.
• Is a threat to self or others requiring restraint (chemical or physical).
• Monitoring and/or intervention of trained medical personnel during transport for
patient and crew safety.
• Transport required by state law/court order.
• Disorientation
• Suicidal Ideations
• Attempts and gestures
• Hallucinations
• Violent or disruptive behavior
• DT’s
• Drug withdrawal symptoms
• Severe anxiety
• Acute episode or exacerbation of paranoia
ANXIETY
Normal human emotion that everyone experiences at times. The symptoms vary widely
but interfere significantly with normal functioning.
There are several types of anxiety disorders including:
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• Mixed Anxiety
• Panic disorder
• Social Anxiety Disorder
• Specific Phobias
• Generalized Anxiety Disorder
• Phobias
• PTSD and Acute Stress Disorder
• Anxiety caused by physiological or external causes
• Separation Anxiety
• Adjustment Disorder
• Anxiety due to Substance
ICD-10 Code Code Description
F06.4 Anxiety disorder due to known physiological condition
F40.00 Agoraphobia, unspecified
F40.01 Agoraphobia with panic disorder
F40.02 Agoraphobia without panic disorder
F40.10 Social phobia, unspecified
F40.11 Social phobia, generalized
F40.210 Arachnophobia
F40.218 Other animal type phobia
F40.220 Fear of thunderstorms
F40.228 Other natural environment type phobia
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F40.230 Fear of blood
F40.231 Fear of injections and transfusions
F40.232 Fear of other medical care
F40.233 Fear of injury
F40.240 Claustrophobia
F40.241 Acrophobia
F40.242 Fear of bridges
F40.243 Fear of flying
F40.248 Other situational type phobia
F40.290 Androphobia
F40.291 Gynephobia
F40.298 Other specified phobia
F40.8 Other phobic anxiety disorders
F40.9 Phobic anxiety disorder, unspecified
F41.0 Panic disorder [episodic paroxysmal anxiety] without agoraphobia
F41.1 Generalized anxiety disorder
F41.3 Other mixed anxiety disorders
F41.8 Other specified anxiety disorders
F41.9 Anxiety disorder, unspecified
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F42 Obsessive-compulsive disorder
F43.0 Acute stress reaction
F43.10 Post-traumatic stress disorder, unspecified
F43.11 Post-traumatic stress disorder, acute
F43.12 Post-traumatic stress disorder, chronic
F43.20 Adjustment disorder, unspecified
F43.21 Adjustment disorder with depressed mood
F43.22 Adjustment disorder with anxiety
F43.23 Adjustment disorder with mixed anxiety and depressed mood
F43.24 Adjustment disorder with disturbance of conduct
F43.25 Adjustment disorder with mixed disturbance of emotions and conduct
F43.29 Adjustment disorder with other symptoms
F51.02 Adjustment insomnia
F93.0 Separation anxiety disorder of childhood
R45.7 State of emotional shock and stress, unspecified
R46.6 Undue concern and preoccupation with stressful events
Z60.0 Problems of adjustment to life-cycle transitions
Z86.51 Personal history of combat and operational stress reaction
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DELIRIUM
• Serious disturbance in a person’s mental abilities that results in a decreased
awareness of one’s environment and confused thinking.
• Delirium can be traced to one or more contributing factors, such as a severe or
chronic medical illness, medication, infection, surgery, or drug or alcohol abuse.
Symptoms: • Reduced awareness of the environment
– Inability to stay focused on a topic
– Wandering attention
– Being easily distracted by unimportant things
• Poor thinking skills (cognitive impairment)
– Poor memory, particularly of recent events
– Difficulty speaking or recalling words
– Difficulty understanding speech
• Behavior changes
– Seeing things that don’t exist (hallucinations)
– Restlessness, agitation, irritability or combative behavior
– Disturbed sleep habits
DEMENTIA
Symptoms
Memory impairment, difficulty with speech, difficulty with motor activity, difficulty
identifying objects, and may have the inability to plan and organize.
Generally in older adults
ICD-10 Code Code Description
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F01.50 Vascular dementia without behavioral disturbance
F01.51 Vascular dementia with behavioral disturbance
F02.80 Dementia in other diseases classified elsewhere without behavioral disturbance
F02.81 Dementia in other diseases classified elsewhere with behavioral disturbance
F03.90 Unspecified dementia without behavioral disturbance
F03.91 Unspecified dementia with behavioral disturbance
F10.27 Alcohol dependence with alcohol-induced persisting dementia
F10.97 Alcohol use, unspecified with alcohol-induced persisting dementia
F13.27 Sedative, hypnotic or anxiolytic dependence with sedative, hypnotic or anxiolytic-induced persisting dementia
F13.97 Sedative, hypnotic or anxiolytic use, unspecified with sedative, hypnotic or anxiolytic-induced persisting dementia
F18.17 Inhalant abuse with inhalant-induced dementia
F18.27 Inhalant dependence with inhalant-induced dementia
F18.97 Inhalant use, unspecified with inhalant-induced persisting dementia
F19.17 Other psychoactive substance abuse with psychoactive substance-induced persisting dementia
F19.27 Other psychoactive substance dependence with psychoactive substance-induced persisting dementia
F19.97 Other psychoactive substance use, unspecified with psychoactive substance-induced persisting dementia
G30.0 Alzheimer's disease with early onset
G30.1 Alzheimer's disease with late onset
G30.8 Other Alzheimer's disease
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G30.9 Alzheimer's disease, unspecified
R41.81 Age-related cognitive decline
ALCOHOL OR DRUG INTOXICATION
A pattern of abuse of alcohol, drugs, chemicals or external agents.
• Severe intoxication
• Unable to care for self
• Unable to ambulate
• Altered level of consciousness
ALCOHOL WITHDRAWAL
Symptoms most often occur within 48-96 hours after the last drink. Symptoms can
include:
• Body tremors
• Changes in mental function
• Agitation, irritability
• Confusion, disorientation
• Decreased attention span
• Delirium
• Hallucinations
• Quick mood changes
• Restlessness, excitement
• Sensitivity to light, sound, touch
• Stupor, sleepiness, fatigue
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ALCOHOL WITHDRAWAL DELIRIUM (AWD)
• Alcohol withdrawal delirium is the most serious form of alcohol withdrawal. It
causes sudden and severe problems in the brain and nervous system.
• Approximately 5% of hospital patients being treated for alcohol withdrawal also
experience AWD.
• AWD is also known as delirium tremens or DT’s.
Coding Changes
• ICD-9-CM subcategory 305.0, alcohol abuse, provides information on whether the
pattern of alcohol use by the patient is continuous, episodic, in remission, or
unspecified.
• The classification of continuous or episodic alcohol abuse or dependence is not
found in ICD-10-CM.
ICD-10 Code Description
F10.10 Alcohol abuse, uncomplicated
F10.120 Alcohol abuse with intoxication, uncomplicated
F10.121 Alcohol abuse with intoxication delirium
F10.129 Alcohol abuse with intoxication, unspecified
HALLUCINATIONS
• Involves seeing things while awake that appear to be real, but instead have been
created by the mind.
• Common hallucinations include:
o Feeling bodily sensations, such as a crawling feeling on the skin.
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o Hearing sounds, such as music or footsteps.
o Hearing voices when no one has spoken.
o Seeing patterns, lights, beings, or objects that aren’t there.
o Smelling a foul or pleasant odor.
ICD-10 Code Description
R44.2 Other hallucinations
R44.3 Hallucinations, unspecified
SCHIZOPHRENIA
Schizophrenia is a serious brain disorder that distorts the way a person thinks, acts,
expresses emotions, perceives reality, and relates to others. People with schizophrenia —
the most chronic and disabling of the major mental illnesses — often have problems
functioning in society, at work, at school, and in relationships.
There are nearly 40 ICD-9-CM codes for Schizophrenia, but only 10 in ICD-10-CM.
ICD-10 Code Description
F20.0 Paranoid schizophrenia
F20.1 Disorganized schizophrenia
F20.2 Catatonic schizophrenia
F20.3 Undifferentiated schizophrenia
F20.5 Residual schizophrenia
F20.8 Other schizophrenia
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F208.1 Schizophreniform disorder
F208.9 Other schizophrenia
F20.9 Schizophrenia, unspecified
F21 Schizotypal disorder
ALTERED LEVEL OF CONSCIOUSNESS
• Any measure of arousal other than normal.
• Level of consciousness (LOC) is a measurement of a person’s arousability and
responsiveness to stimuli from the environment.
• Severe drowsiness in which the patient can be aroused by moderate stimuli and
then drift back to sleep is lethargy.
• State similar to lethargy in which the patient has a lessened interest in the
environment, slowed responses to stimulation, and tends to sleep more than
normal with drowsiness in between sleep states is obtunded.
• Stupor means that only vigorous and repeated stimuli will arouse the individual,
and when left undisturbed, the patient will immediately lapse back to the
unresponsive state.
• Coma is a state of unarousable unresponsiveness.
• Acute condition with Glasgow Coma Scale < 15.
• Transient symptoms of dizziness.
• Associated with neurologic or cardiovascular symptoms and/or signs.
• Abnormal vital signs
GLASGOW COMA SCALE (GCS)
• Neurological scale of recording the conscious state of a person.
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Severe, with GCS < 8–9
Moderate, GCS 8 or 9–12
Minor, GCS ≥ 13.
Comma Scale ICD-10-CM-NEW
The scale below will be used by most other health care providers not EMS in an emergency
situation; however, in non-emergency this code may be used if the Coma Scale is going to
be utilized from another healthcare provider.
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When a GCS is taken by the EMS provider the following ICD-10-CM codes can be utilized if
needed or required by the payor.
R40.241 Glasgow Coma Scale score 13-15
R40.242 Glasgow Coma Scale score 9-12
R40.243 Glasgow Coma Scale score 3-8
When a Glasgow Coma Scale score is not documented and the patient is in a coma, or when only a partial score is reported, assign code:
R40.244, Other coma, without documented Glasgow coma scale score, or with partial score reported.
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Primarily used for registries and research use and never should be used as a
primary diagnosis.
When the total score is provided, then per coding guidelines the ICD-10-CM code
R40.241-R40.243 should be used, R40.21, R40.22 and R40.23 is to only be used
when the total GCS is not available.
ICD-10 Code Description
R40.20 Unspecified coma
R40.0 Somnolence
R40.1 Stupor
R40.3 Persistent vegetative
R41.0 Disorientation, unspecified
R41.81 Age related cognitive decline
R41.82 Altered mental status, unspecified
R41.89 Other symptoms and signs of cognitive functions and awareness
R41.9 Unspecified symptoms involving cognitive functions and awareness
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Diseases of the Nervous System
SLEEP DISORDERS
Coding Changes
• Are now in the Disease of the Nervous System instead of Signs and Symptoms.
ALTIZHIMERS
Coding Changes
• Now reflects onset versus late effects.
EPILEPSY
Epilepsy is a disorder that results from the surges in electrical signals inside the brain,
causing recurring seizures. Seizure symptoms vary. Some people with epilepsy simply
stare blankly for a few seconds during a seizure, while others have convulsions where a
person’s muscles contract and relax repeatedly.
Coding Changes
Terminology
• Localization-related to idiopathic
• Generalized idiopathic
• Special epileptic syndromes
Provide Specificity for:
• Seizures of localized onset
• Complex partial seizures
• Intractable
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• Status epilepticus
– A continuous series of generalized tonic-clonic seizure without return of
consciousness, or any prolonged series of similar seizures without return to
full consciousness between them.
ICD-10 Code
Code Description
F44.5 Conversion disorder with seizures or convulsions
G40.001 Localization-related (focal) (partial) idiopathic epilepsy and epileptic syndromes with seizures of localized onset, not intractable, with status epilepticus
G40.009 Localization-related (focal) (partial) idiopathic epilepsy and epileptic syndromes with seizures of localized onset, not intractable, without status epilepticus
G40.011 Localization-related (focal) (partial) idiopathic epilepsy and epileptic syndromes with seizures of localized onset, intractable, with status epilepticus
G40.019 Localization-related (focal) (partial) idiopathic epilepsy and epileptic syndromes with seizures of localized onset, intractable, without status epilepticus
G40.101 Localization-related (focal) (partial) symptomatic epilepsy and epileptic syndromes with simple partial seizures, not intractable, with status epilepticus
G40.109 Localization-related (focal) (partial) symptomatic epilepsy and epileptic syndromes with simple partial seizures, not intractable, without status epilepticus
G40.111 Localization-related (focal) (partial) symptomatic epilepsy and epileptic syndromes with simple partial seizures, intractable, with status epilepticus
G40.119 Localization-related (focal) (partial) symptomatic epilepsy and epileptic syndromes with simple partial seizures, intractable, without status epilepticus
G40.201 Localization-related (focal) (partial) symptomatic epilepsy and epileptic syndromes with complex partial seizures, not intractable, with status epilepticus
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G40.209 Localization-related (focal) (partial) symptomatic epilepsy and epileptic syndromes with complex partial seizures, not intractable, without status epilepticus
G40.211 Localization-related (focal) (partial) symptomatic epilepsy and epileptic syndromes with complex partial seizures, intractable, with status epilepticus
G40.219 Localization-related (focal) (partial) symptomatic epilepsy and epileptic syndromes with complex partial seizures, intractable, without status epilepticus
G40.301 Generalized idiopathic epilepsy and epileptic syndromes, not intractable, with status epilepticus
G40.309 Generalized idiopathic epilepsy and epileptic syndromes, not intractable, without status epilepticus
G40.311 Generalized idiopathic epilepsy and epileptic syndromes, intractable, with status epilepticus
G40.319 Generalized idiopathic epilepsy and epileptic syndromes, intractable, without status epilepticus
G40.401 Other generalized epilepsy and epileptic syndromes, not intractable, with status epilepticus
G40.409 Other generalized epilepsy and epileptic syndromes, not intractable, without status epilepticus
G40.411 Other generalized epilepsy and epileptic syndromes, intractable, with status epilepticus
G40.419 Other generalized epilepsy and epileptic syndromes, intractable, without status epilepticus
G40.501 Epileptic seizures related to external causes, not intractable, with status epilepticus
G40.509 Epileptic seizures related to external causes, not intractable, without status epilepticus
G40.801 Other epilepsy, not intractable, with status epilepticus
G40.802 Other epilepsy, not intractable, without status epilepticus
G40.803 Other epilepsy, intractable, with status epilepticus
G40.804 Other epilepsy, intractable, without status epilepticus
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G40.811 Lennox-Gastaut syndrome, not intractable, with status epilepticus
G40.812 Lennox-Gastaut syndrome, not intractable, without status epilepticus
G40.813 Lennox-Gastaut syndrome, intractable, with status epilepticus
G40.814 Lennox-Gastaut syndrome, intractable, without status epilepticus
G40.821 Epileptic spasms, not intractable, with status epilepticus
G40.822 Epileptic spasms, not intractable, without status epilepticus
G40.823 Epileptic spasms, intractable, with status epilepticus
G40.824 Epileptic spasms, intractable, without status epilepticus
G40.89 Other seizures
G40.901 Epilepsy, unspecified, not intractable, with status epilepticus
G40.909 Epilepsy, unspecified, not intractable, without status epilepticus
G40.911 Epilepsy, unspecified, intractable, with status epilepticus
G40.919 Epilepsy, unspecified, intractable, without status epilepticus
G40.A01 Absence epileptic syndrome, not intractable, with status epilepticus
G40.A09 Absence epilehallptic syndrome, not intractable, without status epilepticus
G40.A11 Absence epileptic syndrome, intractable, with status epilepticus
G40.A19 Absence epileptic syndrome, intractable, without status epilepticus
G40.B01 Juvenile myoclonic epilepsy, not intractable, with status epilepticus
G40.B09 Juvenile myoclonic epilepsy, not intractable, without status epilepticus
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G40.B11 Juvenile myoclonic epilepsy, intractable, with status epilepticus
G40.B19 Juvenile myoclonic epilepsy, intractable, without status epilepticus
G83.84 Todd's paralysis (postepileptic)
R56.1 Post traumatic seizures
R56.9 Unspecified convulsions
PARALYSIS
• Dominant
• Non-Dominant
• Unspecified
Hemiplegia Category (G81) – Monoplegia Category (G83.3)
If documentation does not define dominant or non-dominant:
• Ambidextrous, the default is dominant
• Left Side, the default is non-dominant
• Right Side, the default is dominant
SEIZURES
• Physical findings or changes in behavior that occur after an episode of
abnormal electrical activity in the brain.
• The term “seizure” is often used interchangeably with “convulsion”.
• Convulsions occur when a person’s body shakes rapidly and uncontrollably.
• Some seizures only cause a person to have staring spells. These may go unnoticed.
Symptoms depend on what part of the brain is involved. They may include:
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• Brief blackout followed by a period of confusion
• Drooling or frothing at the mouth
• Eye movements
• Grunting and snorting
• Loss of bladder or bowel control
• Shaking of entire body
• Tasting a bitter or metallic flavor
• Teeth clenching
• Uncontrollable muscle spasms with twitching and jerking limbs.
Conditions include:
• New onset or untreated seizures
• Significant change in baseline control of seizure activity
• Ongoing seizure activity
• Post-ictal neurologic dysfunction
ICD-10 Code Code Description
R56.00 Simple febrile convulsions
R56.01 Complex febrile convulsions
R56.1 Post traumatic seizures
R56.9 Unspecified convulsions
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TRANSICHEMIC ATTACK (TIA)
• When blood flow to part of the brain stops for a brief period of time.
• A person will have stroke like symptoms up to 24 hours, but in most cases for 1-2
hours.
CEREBROVASCULAR ACCIDENT (CVA)
• A stroke occurs when blood flow to a part of the brain stops.
• If blood flow is cut off for longer than a few seconds, the brain cannot get nutrients
and oxygen.
• Brain cells can die, causing lasting damage.
• This can lead to complete or partial loss of function in the area of the body that is
controlled by the part of the brain that is damaged.
Terms of Cerebrovascular System
• Frontal lobe-conscious thought; damage can result in mood changes, social
differences, etc. The frontal lobes are the most uniquely human of all the brain
structures.
• Parietal lobe-plays important roles in integrating sensory information from
various senses, and in the manipulation of objects; portions of the parietal lobe are
involved with visuospatial processing.
• Occipital lobe-sense of sight; lesions can produce hallucinations
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• Temporal lobe-senses of smell and sound, as well as processing of complex stimuli
like faces and scenes.
• Limbic lobe-emotion, memory.
• Insular cortex-pain, some other senses.
Types of stroke:
• Ischemic stroke
o Occurs when an artery to the brain is
blocked. The brain depends on its arteries to
bring fresh blood from the heart and lungs.
o Is site specific by artery
• Intracerebral hemorrhage
o Occurs when a diseased blood vessel within the brain bursts, allowing blood
to leak inside the brain. (The name means within the cerebrum or brain)
o Specified by location in the brain.
• Subarachnoid hemorrhage
o Bleeding in the space between the brain and the surrounding membrane
(subarachnoid space).
o Specified by specific artery in the brain causing the hemorrhage
Symptoms of a Stroke
• Sudden weakness or paralysis of an arm, a leg, or one side of the body.
• Sudden dimness or loss of vision, particularly in one eye.
• Sudden confusion, with difficulty speaking and understanding speech.
• Loss of balance and coordination, leading to falls.
• Sudden severe headache with no apparent cause.
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• Abnormal sensations or loss of sensation in an arm or a leg or on one side of
the body.
CODING CHANGES
Identifies various forms of CVA’s.
Cerebral hemorrhage
Infraction due to thrombosis
Embolism or
Unspecified occlusion or stenosis in the cerebral vessel.
Sequela of Cerebrovascular Disease (Late Effects in ICD-9-CM)
• Conditions classifiable to categories I60-I67 as the cause of sequelae
(neurologic deficits) which are classified elsewhere.
• Identified by type of stroke
o Hemorrhage or infarction
• The symptoms persist after the initial cerebrovascular disease.
• May arise at any time after the onset of the disease.
ICD-10 Code
Code Description
R42 Dizziness and giddiness
R20.8 Other disturbances of skin sensation
R20.9 Unspecified disturbance of skin sensations
R51 Headache
R29.5 Transient paralysis
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R29.810 Facial weakness
R29.90 Unspecified signs and symptoms involving the nervous system
R47.01 Aphasia
R47.02 Dysphasia
R47.81 Slurred speech
R47.89 Other speech disturbances
MIGRANES
Must include documentation of:
• Intractable (pharmacologically or treatment resistant, medically and poorly
controlled)
• Not Intractable
• With/Without Status of Migrainosus
• With Vomiting, etc.
Status of Migrainosus-Is having visions changes, nausea, vomiting, and difficulty
thinking.
ICD-10 Code
Code Description
G43.601 Persistent migraine aura with cerebral infarction, not intractable, with status migrainosus
G43.609 Persistent migraine aura with cerebral infarction, not intractable, without status migrainosus
G43.611 Persistent migraine aura with cerebral infarction, intractable, with status migrainosus
G43.619 Persistent migraine aura with cerebral infarction, intractable, without status migrainosus
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G45.0 Vertebro-basilar artery syndrome
G45.1 Carotid artery syndrome (hemispheric)
G45.2 Multiple and bilateral precerebral artery syndromes
G45.8 Other transient cerebral ischemic attacks and related syndromes
G45.9 Transient cerebral ischemic attack, unspecified
G46.3 Brain stem stroke syndrome
G46.4 Cerebellar stroke syndrome
G97.51 Postprocedural hemorrhage and hematoma of a nervous system organ or structure following a nervous system procedure
G97.52 Postprocedural hemorrhage and hematoma of a nervous system organ or structure following other procedure
I60.00 Nontraumatic subarachnoid hemorrhage from unspecified carotid siphon and bifurcation
I60.01 Nontraumatic subarachnoid hemorrhage from right carotid siphon and bifurcation
I60.02 Nontraumatic subarachnoid hemorrhage from left carotid siphon and bifurcation
I60.10 Nontraumatic subarachnoid hemorrhage from unspecified middle cerebral artery
I60.11 Nontraumatic subarachnoid hemorrhage from right middle cerebral artery
I60.12 Nontraumatic subarachnoid hemorrhage from left middle cerebral artery
I60.20 Nontraumatic subarachnoid hemorrhage from unspecified anterior communicating artery
I60.21 Nontraumatic subarachnoid hemorrhage from right anterior communicating artery
I60.22 Nontraumatic subarachnoid hemorrhage from left anterior communicating artery
I60.30 Nontraumatic subarachnoid hemorrhage from unspecified posterior communicating artery
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I60.31 Nontraumatic subarachnoid hemorrhage from right posterior communicating artery
I60.32 Nontraumatic subarachnoid hemorrhage from left posterior communicating artery
I60.4 Nontraumatic subarachnoid hemorrhage from basilar artery
I60.50 Nontraumatic subarachnoid hemorrhage from unspecified vertebral artery
I60.51 Nontraumatic subarachnoid hemorrhage from right vertebral artery
I60.52 Nontraumatic subarachnoid hemorrhage from left vertebral artery
I60.6 Nontraumatic subarachnoid hemorrhage from other intracranial arteries
I60.7 Nontraumatic subarachnoid hemorrhage from unspecified intracranial artery
I60.8 Other nontraumatic subarachnoid hemorrhage
I60.9 Nontraumatic subarachnoid hemorrhage, unspecified
I61.0 Nontraumatic intracerebral hemorrhage in hemisphere, subcortical
I61.1 Nontraumatic intracerebral hemorrhage in hemisphere, cortical
I61.2 Nontraumatic intracerebral hemorrhage in hemisphere, unspecified
I61.3 Nontraumatic intracerebral hemorrhage in brain stem
I61.4 Nontraumatic intracerebral hemorrhage in cerebellum
I61.5 Nontraumatic intracerebral hemorrhage, intraventricular
I61.6 Nontraumatic intracerebral hemorrhage, multiple localized
I61.8 Other nontraumatic intracerebral hemorrhage
I61.9 Nontraumatic intracerebral hemorrhage, unspecified
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I62.00 Nontraumatic subdural hemorrhage, unspecified
I62.01 Nontraumatic acute subdural hemorrhage
I62.02 nontraumatic subacute subdural hemorrhage
I62.03 Nontraumatic chronic subdural hemorrhage
I62.1 Nontraumatic extradural hemorrhage
I62.9 Nontraumatic intracranial hemorrhage, unspecified
I63.00 Cerebral infarction due to thrombosis of unspecified precerebral artery
I63.011 Cerebral infarction due to thrombosis of right vertebral artery
I63.012 Cerebral infarction due to thrombosis of left vertebral artery
I63.019 Cerebral infarction due to thrombosis of unspecified vertebral artery
I63.02 Cerebral infarction due to thrombosis of basilar artery
I63.031 Cerebral infarction due to thrombosis of right carotid artery
I63.032 Cerebral infarction due to thrombosis of left carotid artery
I63.039 Cerebral infarction due to thrombosis of unspecified carotid artery
I63.09 Cerebral infarction due to thrombosis of other precerebral artery
I63.10 Cerebral infarction due to embolism of unspecified precerebral artery
I63.111 Cerebral infarction due to embolism of right vertebral artery
I63.112 Cerebral infarction due to embolism of left vertebral artery
I63.119 Cerebral infarction due to embolism of unspecified vertebral artery
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I63.12 Cerebral infarction due to embolism of basilar artery
I63.131 Cerebral infarction due to embolism of right carotid artery
I63.132 Cerebral infarction due to embolism of left carotid artery
I63.139 Cerebral infarction due to embolism of unspecified carotid artery
I63.19 Cerebral infarction due to embolism of other precerebral artery
I63.20 Cerebral infarction due to unspecified occlusion or stenosis of unspecified precerebral arteries
I63.211 Cerebral infarction due to unspecified occlusion or stenosis of right vertebral arteries
I63.212 Cerebral infarction due to unspecified occlusion or stenosis of left vertebral arteries
I63.219 Cerebral infarction due to unspecified occlusion or stenosis of unspecified vertebral arteries
I63.22 Cerebral infarction due to unspecified occlusion or stenosis of basilar arteries
I63.231 Cerebral infarction due to unspecified occlusion or stenosis of right carotid arteries
I63.232 Cerebral infarction due to unspecified occlusion or stenosis of left carotid arteries
I63.239 Cerebral infarction due to unspecified occlusion or stenosis of unspecified carotid arteries
I63.29 Cerebral infarction due to unspecified occlusion or stenosis of other precerebral arteries
I63.30 Cerebral infarction due to thrombosis of unspecified cerebral artery
I63.311 Cerebral infarction due to thrombosis of right middle cerebral artery
I63.312 Cerebral infarction due to thrombosis of left middle cerebral artery
I63.319 Cerebral infarction due to thrombosis of unspecified middle cerebral artery
I63.321 Cerebral infarction due to thrombosis of right anterior cerebral artery
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I63.322 Cerebral infarction due to thrombosis of left anterior cerebral artery
I63.329 Cerebral infarction due to thrombosis of unspecified anterior cerebral artery
I63.331 Cerebral infarction due to thrombosis of right posterior cerebral artery
I63.332 Cerebral infarction due to thrombosis of left posterior cerebral artery
I63.339 Cerebral infarction due to thrombosis of unspecified posterior cerebral artery
I63.341 Cerebral infarction due to thrombosis of right cerebellar artery
I63.342 Cerebral infarction due to thrombosis of left cerebellar artery
I63.349 Cerebral infarction due to thrombosis of unspecified cerebellar artery
I63.39 Cerebral infarction due to thrombosis of other cerebral artery
I63.40 Cerebral infarction due to embolism of unspecified cerebral artery
I63.411 Cerebral infarction due to embolism of right middle cerebral artery
I63.412 Cerebral infarction due to embolism of left middle cerebral artery
I63.419 Cerebral infarction due to embolism of unspecified middle cerebral artery
I63.421 Cerebral infarction due to embolism of right anterior cerebral artery
I63.422 Cerebral infarction due to embolism of left anterior cerebral artery
I63.429 Cerebral infarction due to embolism of unspecified anterior cerebral artery
I63.431 Cerebral infarction due to embolism of right posterior cerebral artery
I63.432 Cerebral infarction due to embolism of left posterior cerebral artery
I63.439 Cerebral infarction due to embolism of unspecified posterior cerebral artery
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I63.441 Cerebral infarction due to embolism of right cerebellar artery
I63.442 Cerebral infarction due to embolism of left cerebellar artery
I63.449 Cerebral infarction due to embolism of unspecified cerebellar artery
I63.49 Cerebral infarction due to embolism of other cerebral artery
I63.50 Cerebral infarction due to unspecified occlusion or stenosis of unspecified cerebral artery
I63.511 Cerebral infarction due to unspecified occlusion or stenosis of right middle cerebral artery
I63.512 Cerebral infarction due to unspecified occlusion or stenosis of left middle cerebral artery
I63.519 Cerebral infarction due to unspecified occlusion or stenosis of unspecified middle cerebral artery
I63.521 Cerebral infarction due to unspecified occlusion or stenosis of right anterior cerebral artery
I63.522 Cerebral infarction due to unspecified occlusion or stenosis of left anterior cerebral artery
I63.529 Cerebral infarction due to unspecified occlusion or stenosis of unspecified anterior cerebral artery
I63.531 Cerebral infarction due to unspecified occlusion or stenosis of right posterior cerebral artery
I63.532 Cerebral infarction due to unspecified occlusion or stenosis of left posterior cerebral artery
I63.539 Cerebral infarction due to unspecified occlusion or stenosis of unspecified posterior cerebral artery
I63.541 Cerebral infarction due to unspecified occlusion or stenosis of right cerebellar artery
I63.542 Cerebral infarction due to unspecified occlusion or stenosis of left cerebellar artery
I63.549 Cerebral infarction due to unspecified occlusion or stenosis of unspecified cerebellar artery
I63.59 Cerebral infarction due to unspecified occlusion or stenosis of other cerebral artery
I63.6 Cerebral infarction due to cerebral venous thrombosis, nonpyogenic
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I63.8 Other cerebral infarction
I63.9 Cerebral infarction, unspecified
I67.81 Acute cerebrovascular insufficiency
I67.82 Cerebral ischemia
I69.30 Unspecified sequela of cerebral infarction
I69.31 Cognitive deficits following cerebral infarction
I69.320 Aphasia following cerebral infarction
I69.321 Dysphasia following cerebral infarction
I69.322 Dysarthria following cerebral infarction
I69.323 Fluency disorder following cerebral infarction
I69.328 Other speech and language deficits following cerebral infarction
I69.331 Monoplegia of upper limb following cerebral infarction affecting right dominant side
I69.332 Monoplegia of upper limb following cerebral infarction affecting left dominant side
I69.333 Monoplegia of upper limb following cerebral infarction affecting right non-dominant side
I69.334 Monoplegia of upper limb following cerebral infarction affecting left non-dominant side
I69.339 Monoplegia of upper limb following cerebral infarction affecting unspecified side
I69.341 Monoplegia of lower limb following cerebral infarction affecting right dominant side
I69.342 Monoplegia of lower limb following cerebral infarction affecting left dominant side
I69.343 Monoplegia of lower limb following cerebral infarction affecting right non-dominant side
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I69.344 Monoplegia of lower limb following cerebral infarction affecting left non-dominant side
I69.349 Monoplegia of lower limb following cerebral infarction affecting unspecified side
I69.351 Hemiplegia and hemiparesis following cerebral infarction affecting right dominant side
I69.352 Hemiplegia and hemiparesis following cerebral infarction affecting left dominant side
I69.353 Hemiplegia and hemiparesis following cerebral infarction affecting right non-dominant side
I69.354 Hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side
I69.359 Hemiplegia and hemiparesis following cerebral infarction affecting unspecified side
I69.361 Other paralytic syndrome following cerebral infarction affecting right dominant side
I69.362 Other paralytic syndrome following cerebral infarction affecting left dominant side
I69.363 Other paralytic syndrome following cerebral infarction affecting right non-dominant side
I69.364 Other paralytic syndrome following cerebral infarction affecting left non-dominant side
I69.365 Other paralytic syndrome following cerebral infarction, bilateral
I69.369 Other paralytic syndrome following cerebral infarction affecting unspecified side
I69.390 Apraxia following cerebral infarction
I69.391 Dysphagia following cerebral infarction
I69.392 Facial weakness following cerebral infarction
I69.393 Ataxia following cerebral infarction
I69.398 Other sequela of cerebral infarction
I97.810 Intraoperative cerebrovascular infarction during cardiac surgery
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I97.811 Intraoperative cerebrovascular infarction during other surgery
I97.820 Postprocedural cerebrovascular infarction during cardiac surgery
I97.821 Postprocedural cerebrovascular infarction during other surgery
O87.3 Cerebral venous thrombosis in the puerperium
O99.411 Diseases of the circulatory system complicating pregnancy, first trimester
O99.412 Diseases of the circulatory system complicating pregnancy, second trimester
O99.413 Diseases of the circulatory system complicating pregnancy, third trimester
O99.419 Diseases of the circulatory system complicating pregnancy, unspecified trimester
O99.42 Diseases of the circulatory system complicating pregnancy, childbirth
O99.43 Diseases of the circulatory system complicating pregnancy, puerperium
R51 Headache
Z86.73 Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits
PAIN
When pain is coding from the nervous system chapter, then signs and symptoms from
psychological factors should be included.
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ICD-10 Code Code Description
G89 Pain, not elsewhere classified
G89.11 Acute pain, not elsewhere classified-Acute pain due to trauma
G89.12 Acute pain, not elsewhere classified-Acute post-thoracotomy pain
G89.18 Acute pain, not elsewhere classified-Other acute post-procedural pain
G89.21 Chronic pain, not elsewhere classified-Chronic pain due to trauma
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G89.22 Chronic pain, not elsewhere classified-Chronic post-thoracotomy pain
G89.28 Chronic pain, not elsewhere classified-Other chronic post-procedural pain
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Diseases of the Circulatory System
The circulatory system is an organ system that permits blood and lymph
circulation to transport nutrients (such as amino acids and electrolytes),
oxygen, carbon dioxide, hormones, blood cells, etc. to and from cells in the
body to nourish it and help to fight diseases, stabilize body temperature
and pH, and to maintain homeostasis.
The circulatory system is made up of the heart and blood vessels.
CARDIAC TERMS
• Right Atrium
o Receives oxygen-poor blood from the body.
• Right Ventricle
o Contracts to pump oxygen-poor blood along the pulmonary arteries to the
lungs.
• Left Atrium
o Receives oxygen rich blood from the pulmonary veins.
• Left Ventricle
o Contracts to pump oxygen rich blood along the aorta to the body
• Pulmonary veins
o Return oxygenated blood from each lung to the left atrium of the heart.
• Superior Vena Cava
o The second largest vein in the human body. Moves blood from the upper half
of the body to the heart.
• Tricuspid Valve
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o Separates the right atrium and right ventricle, allowing blood to enter the
ventricle but not flow back to the atrium.
• Inferior Vena Cava
o Largest vein in the human body. It collects blood from the lower body and
carries it to the heart.
• Pulmonary Valve
o Blood flows from the right ventricle through the pulmonic valve into the
lungs.
• Mitral Valve
o Separates the left atrium and left ventricle.
• Aortic Valve
o Blood flows from the left ventricle to the aorta through the aortic valve.
• Right Coronary Artery
o Supplies blood to the right atrium, right ventricle, and bottom portion of the
left ventricle and back of the septum.
• Left Anterior Descending Coronary Artery
o Supplies blood to the front and bottom of the left ventricle and the front of
the septum.
• Circumflex Coronary Artery
o Supplies blood to the left atrium and the side and back of the left ventricle.
• Left Main Coronary Artery
o Divides into two branches: the circumflex artery and the left anterior
descending artery.
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HYPERTENSION
An abnormal evaluation of systolic and/or diastolic blood pressure.
Conditions:
Essential, Benign, Malignant
Hypertensive Heart and Chronic Kidney Disease
Secondary Hypertension
Relationship:
Renal
Pulmonary, etc.
Coding Changes
• Deletion of the codes: benign, malignant and unspecified.
• Hypertension table is no longer necessary.
Essential (primary) hypertension I10
Includes: High blood pressure
Hypertension (arterial) (benign) (essential) (malignant)
(primary) (systemic)
Overview
Systolic-The top number, higher of the two numbers, measures the pressure in the arteries
when the heart beats. (when the heart muscle contracts)
I 1 0
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Diastolic-The bottom number, lower of the two numbers, measures the pressure in the
arteries between heartbeats (when the heart muscle is resting between beats and refilling
with blood)
• Prehypertension: Systolic (120-139) or Diastolic (80-89)
• High Blood Pressure (Stage 1): Systolic (140-159) or Diastolic (90-99)
• High Blood Pressure (Stage 2): Systolic (160 or higher) or Diastolic (100 or
higher)
• Hypertensive Crisis: Systolic (Higher than 180) or Diastolic (Higher than 110)
Uncontrolled-May be untreated hypertension or hypertension not responding to current
therapeutic regimen.
Controlled-This diagnostic statement usually refers to an existing state of hypertension
under control by therapy.
Standard commonly applied is that a sustained diastolic pressure above 90 mm Hg
and a sustained systolic pressure above 140 mm Hg constitutes hypertension.
ICD-10 Code Code Description
H35.031 Hypertensive retinopathy, right eye
H35.032 Hypertensive retinopathy, left eye
H35.033 Hypertensive retinopathy, bilateral
H35.039 Hypertensive retinopathy, unspecified eye
I10 Essential (primary) hypertension
I11.0 Hypertensive heart disease with heart failure
I11.9 Hypertensive heart disease without heart failure
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I12.0 Hypertensive chronic kidney disease with stage 5 chronic kidney disease or end stage renal disease
I12.9 Hypertensive chronic kidney disease with stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease
I13.0 Hypertensive heart and chronic kidney disease with heart failure and stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease I13.10 Hypertensive heart and chronic kidney disease without heart failure, with stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease I13.11 Hypertensive heart and chronic kidney disease without heart failure, with stage 5 chronic kidney disease, or end stage renal disease I13.2 Hypertensive heart and chronic kidney disease with heart failure and with stage 5 chronic kidney disease, or end stage renal disease
I15.0 Renovascular hypertension
I15.1 Hypertension secondary to other renal disorders
I15.2 Hypertension secondary to endocrine disorders
I15.8 Other secondary hypertension
I15.9 Secondary hypertension, unspecified
I67.4 Hypertensive encephalopathy
O10.011 Pre-existing essential hypertension complicating pregnancy, first trimester
O10.012 Pre-existing essential hypertension complicating pregnancy, second trimester
O10.013 Pre-existing essential hypertension complicating pregnancy, third trimester
O10.019 Pre-existing essential hypertension complicating pregnancy, unspecified trimester
O10.02 Pre-existing essential hypertension complicating childbirth
O10.03 Pre-existing essential hypertension complicating the puerperium
O10.111 Pre-existing hypertensive heart disease complicating pregnancy, first trimester
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O10.112 Pre-existing hypertensive heart disease complicating pregnancy, second trimester
O10.113 Pre-existing hypertensive heart disease complicating pregnancy, third trimester
O10.119 Pre-existing hypertensive heart disease complicating pregnancy, unspecified trimester
O10.12 Pre-existing hypertensive heart disease complicating childbirth
O10.13 Pre-existing hypertensive heart disease complicating the puerperium
O10.211 Pre-existing hypertensive chronic kidney disease complicating pregnancy, first trimester
O10.212 Pre-existing hypertensive chronic kidney disease complicating pregnancy, second trimester
O10.213 Pre-existing hypertensive chronic kidney disease complicating pregnancy, third trimester
O10.219 Pre-existing hypertensive chronic kidney disease complicating pregnancy, unspecified trimester
O10.22 Pre-existing hypertensive chronic kidney disease complicating childbirth
O10.23 Pre-existing hypertensive chronic kidney disease complicating the puerperium
O10.311 Pre-existing hypertensive heart and chronic kidney disease complicating pregnancy, first trimester
O10.312 Pre-existing hypertensive heart and chronic kidney disease complicating pregnancy, second trimester
O10.313 Pre-existing hypertensive heart and chronic kidney disease complicating pregnancy, third trimester
O10.319 Pre-existing hypertensive heart and chronic kidney disease complicating pregnancy, unspecified trimester
O10.32 Pre-existing hypertensive heart and chronic kidney disease complicating childbirth
O10.33 Pre-existing hypertensive heart and chronic kidney disease complicating the puerperium
O10.411 Pre-existing secondary hypertension complicating pregnancy, first trimester
O10.412 Pre-existing secondary hypertension complicating pregnancy, second trimester
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O10.413 Pre-existing secondary hypertension complicating pregnancy, third trimester
O10.419 Pre-existing secondary hypertension complicating pregnancy, unspecified trimester
O10.42 Pre-existing secondary hypertension complicating childbirth
O10.43 Pre-existing secondary hypertension complicating the puerperium
O10.911 Unspecified pre-existing hypertension complicating pregnancy, first trimester
O10.912 Unspecified pre-existing hypertension complicating pregnancy, second trimester
O10.913 Unspecified pre-existing hypertension complicating pregnancy, third trimester
O10.919 Unspecified pre-existing hypertension complicating pregnancy, unspecified trimester
O10.92 Unspecified pre-existing hypertension complicating childbirth
O10.93 Unspecified pre-existing hypertension complicating the puerperium
O11.1 Pre-existing hypertension with pre-eclampsia, first trimester
O11.2 Pre-existing hypertension with pre-eclampsia, second trimester
O11.3 Pre-existing hypertension with pre-eclampsia, third trimester
O11.9 Pre-existing hypertension with pre-eclampsia, unspecified trimester
HYPOTENTION
When blood pressure is too low, not enough blood reaches all parts of the body; as a result,
cells do not receive enough oxygen and nutrients, and waste products are not adequately
removed.
Systolic: 90 or less Diastolic: 60 or less
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Symptoms
• Dizziness or lightheadedness
• Fainting (syncope)
• Lack of concentration
• Blurred vision
• Nausea
• Cold, clammy, pale skin
• Rapid, shallow breathing
• Fatigue
• Depression
• Thirst
ICD-10 Code
Code Description
I95.9 Hypotension
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ELEVATED BLOOD PRESSURE
Elevated blood pressure reading
Elevated blood pressure reading without diagnosis of hypertension (situation)
Elevated blood-pressure reading without diagnosis of hypertension
Elevated BP reading without HTN diagnosis
Finding of increased blood pressure
This category is to be used to record an episode of elevated blood pressure in a
patient in whom no formal diagnosis of hypertension has been made, or as an
isolated incidental finding.
ICD-10 Code
Code Description
R03.0 Elevated Blood Pressure
ACUTE MYOCARDIAL INFARCTION (AMI)
Coding Changes
Timeframe: An AMI is now “acute” for 4 weeks from the time of incident versus 8
weeks with ICD-9.
Episode of Care: ICD-10 does not capture episode of care. (E.g. initial, subsequent
sequelae.
Subsequent: Use a subsequent code if patient had an MI during the 4 weeks “acute
period” of the original AMI.
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STEMI: ST Segment Elevation Myocardial Infarction
Non-STEMI: NON-ST Segment Elevation Myocardial Infarction
Coding Note
If NSTEMI evolves to STEMI, then a STEMI Code is used, if a STEMI converts to NSTEMI due
to thrombolytic therapy, it is still coded to STEMI.
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And LATERALY is USED
MI’s are now specified by artery causing MI
Right Coronary Left Circumflex
Left Main Artery Other Sights
Left Anterior Descending Unspecified Sites
ICD-10 Code Code Description
I21.01 ST elevation (STEMI) myocardial infarction involving left main coronary artery
I21.02 ST elevation (STEMI) myocardial infarction involving left anterior descending coronary artery
I21.09 ST elevation (STEMI) myocardial infarction involving other coronary artery of anterior wall
I21.11 ST elevation (STEMI) myocardial infarction involving right coronary artery
I21.19 ST elevation (STEMI) myocardial infarction involving other coronary artery of inferior wall
I21.21 ST elevation (STEMI) myocardial infarction involving left circumflex coronary artery
I21.29 ST elevation (STEMI) myocardial infarction involving other sites
I21.3 ST elevation (STEMI) myocardial infarction of unspecified site
I21.4 Non-ST elevation (NSTEMI) myocardial infarction
I22.0 Subsequent ST elevation (STEMI) myocardial infarction of anterior wall
I22.1 Subsequent ST elevation (STEMI) myocardial infarction of inferior wall
I22.2 Subsequent non-ST elevation (NSTEMI) myocardial infarction
I22.8 Subsequent ST elevation (STEMI) myocardial infarction of other sites
I22.9 Subsequent ST elevation (STEMI) myocardial infarction of unspecified site
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I23.0 Hemopericardium as current complication following acute myocardial infarction
I23.1 Atrial septal defect as current complication following acute myocardial infarction
I23.2 Ventricular septal defect as current complication following acute myocardial infarction
I23.3 Rupture of cardiac wall without hemopericardium as current complication following acute myocardial infarction
I23.4 Rupture of chordae tendineae as current complication following acute myocardial infarction
I23.5 Rupture of papillary muscle as current complication following acute myocardial infarction
I23.6 Thrombosis of atrium, auricular appendage, and ventricle as current complications following acute myocardial infarction
I23.7 Post infarction angina
I23.8 Other current complications following acute myocardial infarction
I25.2 Old myocardial infarction
ATHEROCLEROTIC HEART DISEASE
• Occurs when the blood vessels that carry oxygen and nutrients from the heart to
the rest of the body and arteries become thick and stiff-sometimes restricting blood
flow to the organs and tissues.
• Healthy arteries are flexible and elastic, but over time, the walls in the arteries can
harden.
• Atherosclerosis is a specific type of arteriosclerosis but the terms are sometimes
used interchangeably.
• Refers to the buildup of fats, cholesterol and other substances in and on the artery
walls (plaques), which can restrict blood flow.
• Symptoms (atherosclerosis in heart arteries)
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o Chest pain or pressure (angina)
Coding Changes
Atherosclerotic Heart Disease with Angina Pectoris
Cause: Assumed to be atherosclerosis
Stability Stable Angina Pectoris or Unstable Angina Pectoris
Vessel: If known, which artery is involved and whether the artery is native or
autologous.
Graft
Involvement: If appropriate, whether a bypass graft was involved in the angina
pectoris diagnosis; also note the original location of the graft and
whether it is autologous or biologic.
ICD-10 Code Code Description
I25.110 Atherosclerotic hearth disease of a native coronary artery with unstable angina
I21.02 Atherosclerosis of autologous vein coronary artery bypass graft(s) with unstable angina
ATRIAL FIBRILLATION AND FLUTTER
The two small upper chambers (atria) of the heart do not beat the way they should. Instead
of beating in a normal pattern, the atria beat irregularly and too fast, quivering like a bowl
of gelatin.
Symptoms
• General fatigue
• Rapid and irregular heartbeat
• Fluttering or thumping in the chest
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• Dizziness
• Shortness of breath and anxiety
• Faintness or confusion
• Fatigue when exercising
• Sweating
Location: Atrial, ventricular, supraventricular, etc.
Rhythm Name: Flutter, fibrillation, sick sinus syndrome.
Acuity: Acute, chronic, etc.
Cause: Hyperkalemia, hypertension, alcohol consumption, digoxin, etc.
ICD-10 Code Code Description
I48.0 Paroxysmal atrial fibrillations
I48.1 Persistent atrial fibrillation
I48.2 Chronic atrial fibrillation
I48.3 Typical atrial flutter
I48.4 Atypical atrial flutter
I48.91 Unspecified atrial fibrillation
I48.92 Unspecified atrial flutter
CARDIAC ARRHYTHMIAS
• Symptomatic or potentially life-threatening arrhythmia.
Necessary symptoms include:
• Syncope or near syncope.
• Chest pain and dyspnea.
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• Includes severe bradycardia or tachycardia.
• Patients are expected to have conditions that require monitoring during and after
transportation.
ICD-10 Code Code Description
I49.01 Ventricular fibrillation
I49.02 Ventricular flutter
I49.1 Atrial premature depolarization
I49.2 Junctional premature depolarization
I49.3 Ventricular premature depolarization
I49.40 Unspecified premature depolarization
I49.49 Other premature depolarization
I49.5 Sick sinus syndrome
I49.8 Other specified cardiac arrhythmias
I49.9 Cardiac arrhythmia
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When to use I49.8
A prime example when an ICD-10-CM Codebook will be useful.
PALPITATIONS
Clinical Information A disorder characterized by an unpleasant sensation of
irregular and/or forceful beating of the heart.
A rapid or irregular heartbeat that a person can feel.
An unpleasant sensation of irregular and/or forceful beating of the heart.
Signs required include severe bradycardia or tachycardia (rate < 60 or > 120).
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When to use Bradycardia
When to use Tachycardia
When to Use Palpitations and Abnormal Heart Rate
DISEASES OF THE CIRCULATORY SYSTEM
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ICD-10 Code Code Description
R00.0 Tachycardia unspecified
R00.1 Bradycardia unspecified
R00.2 Palpitations
R00.8 Other abnormalities of the heart beat
R00.9 Unspecified abnormalities of heart beat
HEART FAILURE
Congestive Heart Failure when fluids build up in various parts of the body in which the
heart cannot pump enough blood to the rest of the body.
Type of Heart Failure
• Systolic Heart Failure: Heart muscle contracts with too little force, causing less
oxygen-rich blood to be pumped (pumping problem).
• Diastolic Heart Failure: Heart contracts normally, but ventricle walls don’t relax
enough to let the chamber fill (filling problem).
Symptoms
• Shortness of breath
• Persistent coughing or wheezing
• Buildup of excess fluid in body tissues (edema)
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• Fatigue
• Lack of appetite or nausea
• Impaired thinking
• Increased heart rate
Conditions:
Congestive heart failure
Left/right heart failure
Systolic/diastolic heart failure
Cardiac arrest
Failure related to hypertensive disease
Acute and chronic heart failure
Heart failure in pregnancy due to anesthesia
Rheumatic heart failure
Coding Changes
Acuity: Acute or Chronic
Decompensation=Chronic
Exacerbation=Acute
Type: Systolic or Diastolic
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ICD-10 Code Description
I50.1 Left ventricular failure
I50.20 Unspecified systolic (congestive) heart failure
I50.21 Acute systolic (congestive) heart failure
I50.22 Chronic systolic (congestive) heart failure
I50.23 Acute on chronic systolic (congestive) heart failure
I50.30 Unspecified diastolic (congestive) heart failure
I50.31 Acute diastolic (congestive) heart failure
I50.32 Chronic diastolic (congestive) heart failure
I50.33 Acute on chronic diastolic (congestive) heart failure
I50.40 Unspecified combined systolic (congestive) and diastolic
(congestive) heart failure I50.41 Acute combined systolic (congestive) and diastolic (congestive) heart
failure I50.42 Chronic combined systolic (congestive) and diastolic (congestive)
heart failure I50.43 Acute on chronic combined systolic (congestive) and diastolic
(congestive) heart failure I50.9 Heart failure, unspecified
CARDIOMYOPATHY
Type: Dilated/congestive, obstructive or non-obstructive hypertrophic, etc.
Location: Endocarditis, right ventricle, etc.
Cause: Congenital, alcohol, etc.
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ICD-10 Code Description
I42.0 Dilated cardiomyopathy
I42.1 Obstructive hypertrophic cardiomyopathy
I42.3 Endomyocardial disease
CHEST PAIN
• Pain usually characterized as severe, tight, dull, crushing, substernal, epigastric, or
left sided.
• Associated pain of the jaw, left arm, neck, back
• GI symptoms (such as nausea or vomiting)
• Arrhythmias
• Palpitations
• Difficulty breathing
• Pallor
• Diaphoresis
• Alteration of consciousness
ICD-10 Code Description
R07.1 Chest pain on breathing
R07.2 Percordial pain
R07.81 Pleurodynia
R07.82 Intercostal pain
R07.89 Other chest pain
DISEASES OF THE CIRCULATORY SYSTEM
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R07.9 Chest pain unspecified
SYNCOPE AND COLLAPSE
• A disorder characterized by spontaneous loss of consciousness caused by
insufficient blood supply to the brain.
• A spontaneous loss of consciousness caused by insufficient blood supply to the
brain.
• A spontaneous loss of consciousness caused by insufficient blood to the brain.
• A transient loss of consciousness and postural tone caused by diminished blood
flow to the brain (i.e., brain ischemia). Presyncope refers to the sensation of
lightheadedness and loss of strength that precedes a syncopal event or
accompanies an incomplete syncope.
• Extremely weak; threatened with syncope.
• Fainting due to a sudden fall of blood pressure below the level required to maintain
oxygenation of brain tissue.
• Fainting usually happens when the blood pressure drops suddenly, causing a
decrease in blood flow to the brain. Some causes of fainting include:
o heat or dehydration
o emotional distress
o standing up too quickly
o certain medicines
o drop in blood sugar
o heart problems
• Loss of consciousness due to a reduction in blood pressure that is associated
with an increase in vagal tone and peripheral vasodilation.
ICD-10 Code Description
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R55 Syncope and collapse
PULMONARY EMBOLISM
• One or more pulmonary arteries in the lungs become blocked.
• In most cases, pulmonary embolism is caused by blood clots that travel to the lungs
from the legs or rarely other parts of the body. (DVT)
Common signs and symptoms
• Shortness of breath
• Chest Pain
• Cough
Other signs and symptoms that can occur with PE
• Leg pain or swelling, or both, usually in calf
• Clammy or discolored skin
• Excessive Sweating
• Rapid or irregular heartbeat
• Lightheadedness or dizziness
CARDIAC ARREST
• Abrupt loss of heart function in a person who may or may not have diagnosed heart
disease.
• The term “heart attack” is often mistakenly used to describe cardiac arrest. While
a heart attack may cause cardiac arrest and sudden death, the terms don’t mean the
same thing.
Coding Changes
Cardiac Arrest (427.5) Goes from 1 Code to 1 of 7 Codes.
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ICD-10 Code Description
I46.2 Cardiac arrest due to underlying cardiac condition
I46.8
Cardiac arrest due to other underlying cardiac condition
I46.9 Cardiac arrest, cause unspecified
I97.120 Postprocedural cardiac arrest following cardiac surgery
I97.121 Postprocedural cardiac arrest following other surgery
I97.710 Intraoperative cardiac arrest during cardiac surgery
I97.711
Intraoperative cardiac arrest during other surgery
DISEASES OF THE RESPIRATORY SYSTEM
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Diseases of the Respiratory System
• The respiratory system draws oxygen into the body and removes carbon dioxide.
• The body cells use oxygen to release the energy they need to live. Energy is released
by a process called cell respiration.
• This process also releases waste carbon dioxide, which has to be removed before it
poisons the body.
• The respiratory system consists of the lungs and the air passages that carry air to
and from the lungs.
• It works by drawing “fresh” air containing oxygen into the body and pushing out
“stale” air containing carbon dioxide.
• A person can never take a break from breathing. People breathe around 20,000
times a day because their cells need a constant supply of oxygen.
Upper respiratory tract:
Nose or nostrils, nasal cavity, mouth, throat (pharynx), and voice box (larynx).
Lower respiratory tract:
Windpipe (trachea) and within the lungs, the bronchi, bronchioles, and alveoli.
RESPIRATORY TERMS
• Mechanical Ventilation
Clinically indicated for patient with apnea, acute respiratory failure and impending
acute respiratory failure. Invasive mechanical ventilation pumps air into the
patient’s lungs even where there is no attempt by the patient to breath on their own.
• Nasopharyngeal Airway
o Also known as an NPA, nasal trumpet (because of its flared end), or nose
hose, a type of airway adjunct, is a tube that is designed to be inserted into
the nasal passageway to secure an open airway.
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• Oral Airway
o Is a medical device called an airway adjunct used to maintain or open a
patient's airway. It does this by preventing the tongue from covering the
epiglottis, which could prevent the person from breathing.
• Endotracheal Intubation
o Is the placement of a flexible plastic tube into the trachea (windpipe) to
maintain an open airway or to serve as a conduit through which to
administer certain drugs.
• Kings Airway
o Is an airway device is a disposable supraglottic airway and is reported to be
the safest and most reliable disposable supraglottic airway tool alternative
for emergency ventilation when direct laryngoscopy is not feasible or mask
ventilation is deemed insufficient.
• Continuous Positive Airway Pressure (CPAP’s)
o A machine that increases air pressure in the throat so airway doesn't
collapse when a person breathes in.
RESPIRATORY DOCUMENTATION
• Tachypnea
• Labored respiration
• Hypoxemia
• Requiring oxygen administration
• Require advanced airway management such as ventilator management
• Apnea monitoring for possible intubation
• Deep airway suctioning
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CODING CHANGES
ICD-10-CM codes are grouped by:
Upper and lower respiratory tract infections
Diseases of the pleura and intraoperative
Post-procedural complications; and
Disorders of the respiratory system
Mechanical Ventilation Complications
This was in the Complication Chapter of ICD-9-CM, it is now in the Disease of the
Respiratory.
ICD-10 Code Description
J95.00 Tracheostomy complications
J95.09
Other tracheostomy complications
J95.850 Mechanical complication of respirator
I95.851 Ventilator associated pneumonia
J95.859 Other complication of respirator ventilator
J95.89 Other post procedure complications and disorders of respiratory
system, NEC
ICD-9-CM ICD-10-CM
Acute Anatomic site of infection
Other Severity
Pneumonia Cause
Chronic Acute, other, then chronic
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ASTHMA
• Asthma is a chronic lung disease that inflames and narrows the airways.
• Asthma causes recurring periods of wheezing (a whistling sound when you
breathe), chest tightness, shortness of breath, and coughing.
o The coughing often occurs at night or early in the morning.
• Airways are tubes that carry air into and out of lungs.
• People who have asthma have inflamed airways.
o The inflammation makes the airways swollen and very sensitive.
o The airways tends to react strongly to certain inhaled substances.
o When the airways react, the muscles around them tighten.
o This narrows the airways, causing less air to flow into the lungs.
o The swelling also can worsen, making the airways even narrower.
o Cells in the airways might make more mucus than usual.
o Mucus is a sticky thick liquid that can further narrow the airways.
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Coding Changes
Stages of Asthma
Defined by the World Allergy Organization
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ICD-10 Code Code Description
J45.20 Mild intermittent asthma, uncomplicated
J45.21 Mild intermittent asthma with (acute) exacerbation
J45.22 Mild intermittent asthma with status asthmaticus
J45.30 Mild persistent asthma, uncomplicated
J45.31 Mild persistent asthma with (acute) exacerbation
J45.32 Mild persistent asthma with status asthmaticus
J45.40 Moderate persistent asthma, uncomplicated
J45.41 Moderate persistent asthma with (acute) exacerbation
J45.42 Moderate persistent asthma with status asthmaticus
J45.50 Severe persistent asthma, uncomplicated
J45.51 Severe persistent asthma with (acute) exacerbation
J45.52 Severe persistent asthma with status asthmaticus
J45.901 Unspecified asthma with (acute) exacerbation
J45.902 Unspecified asthma with status asthmaticus
J45.909 Unspecified asthma, uncomplicated
J45.990 Exercise induced bronchospasm
J45.991 Cough variant asthma
J45.998 Other asthma
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COPD
• Chronic obstructive pulmonary disease refers to a group of lung diseases that block
airflow and make breathing difficult.
• Emphysema and chronic bronchitis are the two most common conditions that make
up COPD.
• Chronic bronchitis is an inflammation of the lining of the bronchial tubes, which
carry air to and from the lungs.
• Emphysema occurs when the air sacs (alveoli) at the end of the smallest air
passages (bronchioles) in the lungs are gradually destroyed.
• The main cause of COPD is tobacco smoking. However, in the developing world,
COPD often occurs in women exposed to fumes from burning fuel for cooking and
heating in poorly ventilated homes.
Symptoms
• Shortness of breath
• Wheezing
• Chest tightness
• Having to clear the throat first thing in the morning due to excess mucus in the
lungs.
• A chronic cough that produces sputum that may be clear, white, yellow or greenish.
• Blueness of the lips or fingernail beds (cyanosis).
• Frequent respiratory infections.
• Lack of energy.
• Unintended weight loss (in later stages).
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COPD Exacerbation
• Acute exacerbation of chronic obstructive bronchitis and asthma
• Uncomplicated cases
• With acute lower respiratory tract infection
• Acute exacerbation.
An acute exacerbation is not equivalent to an infection superimposed on a chronic
condition.
An exacerbation may be triggered by an infection.
ICD-10 Code Code Description
J41.0 Simple chronic bronchitis
J41.1 Mucopurulent chronic bronchitis
J41.8 Mixed simple and mucopurulent chronic bronchitis
J42 Unspecified chronic bronchitis
J43.0 Unilateral pulmonary emphysema [MacLeod's syndrome]
J43.1 Panlobular emphysema
J43.2 Centrilobular emphysema
J43.8 Other emphysema
J43.9 Emphysema, unspecified
J44.0 Chronic obstructive pulmonary disease with acute lower respiratory infection
J44.1 Chronic obstructive pulmonary disease with (acute) exacerbation
J44.9 Chronic obstructive pulmonary disease, unspecified
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J98.3 Compensatory emphysema
PULMONARY EDEMA
Pulmonary edema is a condition caused by excess fluid in the lungs. This fluid collects in
the numerous air sacs in the lungs, making it difficult to breathe.
Symptoms include:
Extreme shortness of breath.
A feeling of suffocating or drowning.
Wheezing or gasping for breath.
Anxiety, restlessness or sense of apprehension.
Cough that produces frothy sputum and may be tinged with blood.
Chest pain if pulmonary edema is caused by heart disease.
A rapid, irregular heartbeat (palpitations).
Pneumonia is an infection of the small air sacs of the lungs (alveoli) and the tissues
around them.
The air sacs fill with fluid or pus, causing cough with phlegm or pus, fever, chills and
difficulty breathing.
ICD-10 Code Code Description
J81.0 Acute pulmonary edema
J81.1 Chronic pulmonary edema
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PNEUMONIA
Pneumonia is an infection of the small air sacs of the lungs (alveoli) and the tissues around
them. The air sacs fill with fluid or pus, causing cough with phlegm or pus, fever, chills and
difficulty breathing.
Symptoms
• Cough that produces sputum
• Chest pain
• Chills
• Fever
• Shortness of breath
ICD-10 Code Code Description
J18.8 Other pneumonia, unspecified organism
J18.9 Pneumonia, unspecified organism
ACUTE RESPIRATORY DISTRESS SYNDROME (ARDS)
(Acute Pulmonary Insufficiency)
Type of lung failure resulting from many different disorders that cause fluid to accumulate
in the lungs and oxygen levels in the blood to be too low.
• This deprives the organs of the oxygen they need to function.
• Typically occurs in people who are already critically ill or who have significant
injuries.
Symptoms
• Severe shortness of breath
• Labored and unusually rapid breathing
• Low blood pressure
DISEASES OF THE RESPIRATORY SYSTEM
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• Confusion and extreme tiredness
ICD-10 Code Code Description
J80.0 Acute respiratory distress syndrome
HYPOXIA AND HYPERCAPNIA
Hypoxia
A condition in which the body or a region of the body is deprived of adequate oxygen
supply.
Hypercapnia
A condition of abnormally elevated carbon dioxide (CO2) levels in the blood.
ICD-10 Code Code Description
R09.02 Hypoxemia
RESPIRATORY FAILURE
Respiratory Failure is a condition in which the level of oxygen in the blood becomes
dangerously low or the level of carbon dioxide becomes dangerously high.
Symptoms
• Cyanosis
DISEASES OF THE RESPIRATORY SYSTEM
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• Confusion
• Sleepiness
• Deep, rapid breathing
• Deteriorating consciousness or unconsciousness
• Arrhythmias
ICD-10 Code Code Description
J96.00 Acute respiratory failure, unspecified with hypoxia or hypercapnia
J96.01 Acute respiratory failure with hypoxia
J96.02 Acute respiratory failure with hypercapnia
J96.10 Chronic respiratory failure, unspecified with hypoxia and hypercapnia
J96.11 Chronic respiratory failure with hypoxia
J96.12 Chronic respiratory failure with hypercapnia
J96.20 Acute and chronic respiratory failure, unspecified with hypoxia or hypercapnia
J96.21 Acute and chronic respiratory failure with hypoxia
J96.22 Acute and chronic respiratory failure with hypercapnia
J96.90 Unspecified respiratory failure, unspecified with hypoxia or hypercapnia
J96.91 Unspecified respiratory failure with hypoxia
J96.92 Unspecified respiratory failure with hypercapnia
RESPIRATORY ABNORMALITY
When the body is short of breath, it's hard or uncomfortable to take in the oxygen
the body needs. A person may feel as if they are not getting enough air.
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Sometimes mild breathing problems are from a stuffy nose or hard exercise. But
shortness of breath can also be a sign of a serious disease.
If someone has trouble breathing, it is important to find out the cause.
ICD-10 Code Code Description
R06.00 Dyspnea, unspecified
R06.02 Shortness of breath
R06.09 Other forms of dyspnea
R06.3 Periodic breathing
R06.4 Hyperventilation
R06.82 Tachypnea, not elsewhere classified
R06.83 Snoring
R06.89 Other abnormalities of breathing
DISEASES OF THE DIGESTIVE SYSTEM
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Diseases of the Digestive System
Coding Changes
• Hemorrhage is used for ulcers.
• Bleeding is used for gastritis, duodenitis, diverticulosis and
diverticulitis.
• “Obstruction” is no longer an axis of classification.
o ICD-9-CM
Acute Gastric Ulcer with hemorrhage and
Obstruction.
o ICD-10-CM
Acute Gastric Ulcer with Hemorrhage.
• Complications of artificial openings, including colostomy, enterostomy and
gastrostomy infections and malfunctions are all included in the digestive disease
chapter.
ICD-10 Code Code Description
K29.00 Acute gastritis without bleeding
K29.01 Acute gastritis with bleeding
K29.70 Gastritis, unspecified without bleeding
K56.69 Other intestinal obstruction
K92.2 Gastrointestinal hemorrhage, unspecified
J92.0 Hematemesis
J92.1 Melena
DISEASES OF THE DIGESTIVE SYSTEM
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J92.2 Gastrointestinal hemorrhage, unspecified
K92.81 Gastrointestinal muscositis
K92.89 Other specified diseases of the digestive system
K92.9 Disease of digestive system unspecified
ABDOMINAL PAIN
Location: Generalized, right upper quadrant, periumbilical, etc.
Pain or Tenderness type: Colic, tenderness, rebound, etc.
Documentation:
Accompanied by other signs or symptoms
Associated symptoms include nausea, vomiting, fainting.
Associated signs include tender or pulsatile mass, distention, rigidity, rebound
tenderness on exam, guarding.
ICD-10 Code Code Description
R10.0 Acute abdominal pain
R10.9 Unspecified abdominal pain
R10.11 Abdominal right upper quadrant pain
R10.12 Abdominal left upper quadrant pain
R10.31 Abdominal right lower quadrant pain
R10.32 Abdominal left lower quadrant pain
DISEASES OF THE DIGESTIVE SYSTEM
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R10.33 Periumbilical pain
R10.13 Epigastric pain
R10.84 Generalized abdominal pain
R10.10 Upper abdominal pain, unspecified
R10.2 Pelvic and perineal pain
R10.30 Lower abdominal pain, unspecified
R19.07 Generalized intra-abdominal pelvic swelling, mass, and lump
R19.09 Other intra-abdominal pelvic swelling, mass and lump
R19.30 Abdominal rigidity, unspecified site
R10.819 Abdominal tenderness, unspecified site
R10.829 Rebound abdominal tenderness, unspecified sit
R10.817 Generalized abdominal tenderness
R10.827 Generalized rebound abdominal tenderness
R10.819 Abdominal tenderness, unspecified site
R10.829 Rebound abdominal tenderness, unspecified site
NAUSEA/VOMITING
Expelling the contents of the stomach and the sensations associated with it. They are
symptoms of an underlying disease or condition and not a specific illness.
DISEASES OF THE DIGESTIVE SYSTEM
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Nausea and Vomiting in an emergency situation should have other contraindications,
such as:
vomited for longer than 24 hours
blood in the vomit
severe abdominal pain
headache and stiff neck
signs of dehydration, such as dry mouth, infrequent urination or dark urine
ICD-10 Code Code Description
R11.0 Nausea
R11.10 Vomiting unspecified
R11.11 Vomiting without nausea
R11.12 Projectile vomiting
R11.13 Vomiting of fecal mater
R11.14 Billous vomiting
R11.2 Nausea with vomiting, unspecified
DISEASE OF THE SKIN AND SUBCUTANEOUS TISSUES
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Disease of the Skin and Subcutaneous Tissues
CELLULITIS
An acute inflammation of a localized area of tissue.
DERMATITIS
Is the inflammation of the skin.
ERYTHEMATOUS CONDITIONS
Is a redness of the skin due to capillary dilation.
PRESSURE ULCER OR DECUBITUS ULCER
Caused by hypoxia secondary to pressure-induced vascular insufficiency.
Documentation
Location
Size
Stage of the ulcer
Other information that would explain why a wheelchair or other means of moving
the patient other than an ambulance could not be used.
Decubitus Ulcer Staging
Stage I: A reddened area on the skin that, when pressed, does not turn white.
Stage II: The skin blisters or forms an open sore. The area around the sore may be
red and irritated.
Stage III: The skin now develops an open, sunken hole called a crater. There is
damage to the tissue below the skin.
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Stage IV: The pressure ulcer has become so deep that there is damage to the muscle
and bone, and sometimes to tendons and joints.
CODING CHANGES
Combination codes identify the site of a pressure ulcer as well as the stage of the
ulcer.
If the pressure ulcer is documented as completely healed than it is not coded.
If the pressure ulcer is healing it should be coded to the highest stage that is healing.
Laterality is included with many diagnoses.
Dermatitis and Eczema are used synonymously.
Non-pressure chronic ulcers are also specified by site, laterality, and severity.
Chronic or non-pressure ulcers are usually caused by other conditions and should
be coded first, if known.
The 6th Character level in L89 denotes the “depth of the Ulcer” i.e. L89.503, “stage
3”, pressure ulcer of the ankle, unspecified.
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ABNORMAL SKIN SIGNS
Includes:
Diaphoresis-Sweating, especially to an unusual degree as a symptom of disease or
side effect of a disease.
Cyanosis-Bluish discoloration of the skin resulting from poor circulation or
inadequate oxygenation of the blood.
Delayed capillary refill-How long it takes color to return to an external capillary
bed after pressure is applied.
Diminish skin turgor-The skin’s ability to change shape and return to normal
elasticity.
Mottled skin-Patch skin color areas where the skin color is irregular.
ICD-10 Code Code Description
R23.0 Cyanosis
R23.1 Pallor
R23.2 Flushing
R23.4 Changes in skin texture
R23.8 Other skin changes
R23.9 Unspecified skin changes
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R60.0 Localized edema
R60.1 Generalized edema
R60.9 Edema unspecified
R61 Generalized hyperhidrosis
DISEASES OF THE MUSCULOSKELETAL SYSTEM
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Diseases of the Musculoskeletal System
CODING CHANGES
Almost all the ICD-10 codes have been expanded.
Most codes provide for laterality and site.
LATERALITY
ARTHRITIS
In ICD-10-CM, there are specific codes for primary and secondary arthritis.
Within the secondary arthritis codes there are specific codes for post-traumatic
osteoarthritis and other secondary osteoarthritis.
For secondary osteoarthritis of the hip there is also a code for dysplastic
osteoarthritis.
Arthritis codes in ICD-10-CM is both similar and different than ICD-9-CM.
DISEASES OF THE MUSCULOSKELETAL SYSTEM
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In ICD-9, osteoarthritis can be described as degenerative, hypertrophic, or
secondary to other factors, and the type as generalized or localized.
In ICD-10 provides more options for the coding osteoarthritis related encounters,
including:
o Generalized forms of osteoarthritis or arthritis where multiple joints are
involved.
o Localized forms of osteoarthritis with more specificity that includes primary
versus secondary types, subtypes, laterality, and joint involvement.
o Indicate the type, location, and specific bones and joints (multiple sites if
applicable) involved in the disease. In addition, describe any related
underlying diseases or conditions.
BACK PAIN
Sudden onset, severe non-traumatic pain suggestive of cardiac or vascular origin or
requiring special positioning only available by ambulance.
7–10 on 10-point severity scale.
Neurologic symptoms and/or signs.
Absent leg pulses.
Pulsatile abdominal mass, concurrent chest or abdominal pain.
DISEASES OF THE MUSCULOSKELETAL SYSTEM
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DISEASES OF THE MUSCULOSKELETAL SYSTEM
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CONTRACTURES
Abnormal shortening of muscle tissue, rendering the muscle highly resistant to passive
stretching.
There should be a description about whether the patient has upper or lower limb
contracture(s).
The location and severity/degree of the contracture should be documented.
Lower extremity contractures must be of sufficient degree as to prohibit sitting in
a wheelchair (severe fixed contractures at or proximal to the knee).
DISEASES OF THE MUSCULOSKELETAL SYSTEM
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GENITOURINARY
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Genitourinary
HEMATURIA
Hematuria
Is the presence of blood in the urine.
Gross Hematuria
Is presence of blood in the urine in sufficient quantity to be visible to the naked eye.
Cause
UTI’s
Benign Prostatic Hypertrophy
Ureteral Calculi
Cardinal Sign of bladder cancer.
KIDNEY FAILURE
A clinical syndrome associated with the retention of renal waste products or uremic toxins
in the blood. It is usually the result of renal insufficiency. Most uremic toxins are end
products of protein or nitrogen catabolism, such as urea or creatinine. Severe uremia can
lead to multiple organ dysfunctions with a constellation of symptoms.
A condition in which the kidneys stop working and are not able to remove waste and extra
water from the blood or keep body chemicals in balance.
Chronic Kidney Disease
Has five stages based on the patients glomerular filtration rate (GFR).
Care of a patient with stage IV and V is very intense and complicated.
Chronic renal insufficiency is a form of chronic kidney disease.
A neoplastic or non-neoplastic condition affecting the kidney.
GENITOURINARY
Page 170
Conditions in which the function of kidneys deteriorates suddenly in a matter of
days or even hours.
It is characterized by the sudden drop in glomerular filtration rate.
Impairment of health or a condition of abnormal functioning of the kidney.
Pathological processes of the kidney or its component tissues.
Chronic Renal Failure maybe due to:
High Blood Pressure
Diabetes
Chronic renal failure is irreversible and requires hemodialysis.
Signs and Symptoms
Excess in the blood of urea,
creatinine and other nitrogenous end products of protein and
amino acid metabolism.
End Stage Renal Disease (ESRD)
Is the final stage of the loss of kidney function (also referred to as “Stage V”). This stage
will require transplant of renal dialysis for survival.
Renal Insufficiency
Poor function of the kidneys that may be due to a reduction in blood-flow to the kidneys
caused by renal artery disease. Normally, the kidneys regulate body fluid and blood
pressure, as well as regulate blood chemistry and remove organic waste.
Acute Renal Failure
Occurs suddenly, and usually due to trauma, infection, inflammation or toxicity. It develops
quickly and usually reversible as the underlying condition is treated.
GENITOURINARY
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CODING CHANGES
Many diagnoses are based on gender.
Prostatic hypertrophy is now “enlarged prostrate”.
There are several notes throughout the chapter identifying to use additional codes.
ICD-10 Code Code Description
I12.0 Hypertensive chronic kidney disease with stage 5 chronic kidney disease or end stage renal disease
I13.11 Hypertensive heart and chronic kidney disease without heart failure, with stage 5 chronic kidney disease, or end stage renal disease
I13.2 Hypertensive heart and chronic kidney disease with heart failure and with stage 5 chronic kidney disease, or end stage renal disease
N13.8 Urinary obstruction
N17.8 Other acute kidney failure
N17.9 Acute kidney failure, unspecified
N18.1 Chronic kidney disease, stage 1
N18.2 Chronic kidney disease, stage 2
N18.3 Chronic kidney disease, stage 3
N18.4 Chronic kidney disease, stage 4
N18.5 Chronic kidney disease, stage 5
N18.6 End stage renal disease
N19 Unspecified kidney failure
N39.41 Urinary incontinence-urge incontinence
GENITOURINARY
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N39.42 Urinary incontinence-without sensory awareness
N39.43 Urinary incontinence-post-void dribbling
N39.44 Urinary incontinence-nocturnal enuresis
N39.45 Urinary incontinence-continuous leakage
N39.46 Urinary incontinence-mixed incontinence (urge and stress)
N39.490 Other specified urinary incontinence-overflow incontinence
N39.498 Other specified urinary incontinence (reflex or total incontinence)
N39.8 Other specified disorder of urinary system
N39.9 Disorder of urinary system, unspecified
N99.510 Cystostomy hemorrhage
N99.511 Cystostomy infection
N99.512 Cystostomy malfunction
N99.518 Other cystostomy complication
N99.520 Hemorrhage of other external stoma of urinary tract
N99.521 Infection of other external stoma of urinary tract
N99.522 Malfunction of other external stoma of urinary tract
N99.528 Other external stoma of urinary tract
N99.530 Hemorrhage of other stoma of urinary tract
N99.531 Infection of other stoma of urinary tract
GENITOURINARY
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N99.532 Malfunction of other stoma of urinary tract
N99.538 Other stoma of urinary tract complications
R30 Hematuria
R33.8 Urinary retention
R35.1 Nocturia
R39.11 Urinary hesitancy
R39.12 Weak urinary system
R39.14 Incomplete bladder emptying
R39.15 Urinary urgency
R39.16 Straining on urination
R39.81 Functional urinary incontinence
R39.89 Other symptoms and signs involving the genitourinary system
R39.9 Unspecified symptoms and signs involving the genitourinary system
Z99.2 Dependence on renal dialysis
PREGNANCY, CHILDBIRTH AND THE PUERPERIUM
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Pregnancy, Childbirth and the Puerperium
PREGNANCY, CHILDBIRTH AND THE PUERPERIUM
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POSTPARTUM
The period begins immediately after delivery and continues for six weeks following
delivery.
A postpartum complication is any complication occurring within the six-week period.
CODING GUIDELINES
If an OB patient with diabetes it’s coded to the Diabetes code in the pregnancy,
childbirth and puerperium chapter followed by an E Code from Chapter 4.
If Gestational Diabetes only a code from the pregnancy, childbirth and puerperium
chapter is coded.
If pregnancy complications occur because of alcohol and tobacco use during
pregnancy code from the pregnancy, childbirth and puerperium chapter first,
followed by a code from chapter 5.
If there is a poisoning, toxic effects, adverse effects and underdosing in an OB
Patient, code first O9A.2 Injury, poisoning and certain other consequences of
external causes should be sequenced first, followed by a code to identify the
substance and the condition that is being treated.
If a baby is born, then the gestation needs to be coded from the Z34 codes.
ICD-10 Code Code Description
O24.011 Pre-existing diabetes mellitus, type 1, 1st trimester
O24.012 Pre-existing diabetes mellitus, type 1, 2nd trimester
O24.013 Pre-existing diabetes mellitus, type 1, 3rd trimester
O24.019 Pre-existing diabetes mellitus, type 1, unspecified
PREGNANCY, CHILDBIRTH AND THE PUERPERIUM
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O24.111 Pre-existing diabetes mellitus, type 2, 1st trimester
O24.112 Pre-existing diabetes mellitus, type 2, 1st trimester
O24.113 Pre-existing diabetes mellitus, type 2, 1st trimester
O24.119 Pre-existing diabetes mellitus, type 2, 1st trimester
O24.311 Unspecified pre-existing diabetes mellitus in pregnancy, 1st trimester
O24.312 Unspecified pre-existing diabetes mellitus in pregnancy, 2nd trimester
O24.313 Unspecified pre-existing diabetes mellitus in pregnancy, 3rd trimester
O24.319 Unspecified pre-existing diabetes mellitus in pregnancy, unspecified trimester
O24.410 Gestational diabetes mellitus in pregnancy, diet controlled
O24.414 Gestational diabetes mellitus in pregnancy, insulin controlled
O24.419 Gestational diabetes mellitus in pregnancy, unspecified controlled
O24.811 Other pre-existing diabetes mellitus, 1st trimester
O24.812 Other pre-existing diabetes mellitus, 2nd trimester
O24.813 Other pre-existing diabetes mellitus, 3rd trimester
O24.819 Other pre-existing diabetes mellitus, unspecified trimester
O24.911 Unspecified diabetes mellitus, 1st trimester
O24.912 Unspecified diabetes mellitus, 2nd trimester
O24.913 Unspecified diabetes mellitus, 3rd trimester
O24.919 Unspecified diabetes mellitus, unspecified trimester
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075.9 Complication of labor and delivery, unspecified
O80 Encounter for full-term uncomplicated delivery
O9A.211 Injury, poisoning, and certain external causes complicating pregnancy, 1st trimester
O9A.212 Injury, poisoning, and certain external causes complicating pregnancy, 2nd trimester
O9A.213 Injury, poisoning, and certain external causes complicating pregnancy, 3rd trimester
O9A.219 Injury, poisoning, and certain external causes complicating pregnancy, unspecified trimester
BIRTH
If a baby is born while in transport, then an ICD-10 code from the Z38 is coded for live born
infant.
ICD-10 Code Code Description
Z38.1 Single live born outside of hospital
Z38.4 Twins live born outside of hospital
Z38.7 Multiple live born outside of hospital
R68.13 Apparent life threatening event of an infant
INJURY, POISONING AND CERTAIN OTHER CONSEQUENCES OF EXTERNAL CAUSES
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Injury, Poisoning and Certain Other Consequences of External Causes
INJURY, POISONING AND CERTAIN OTHER CONSEQUENCES OF EXTERNAL
CAUSES
INJURIES
Episode of Care: Initial, subsequent, sequelae
Injury site: Be as specific as possible
Etiology: How was the injury sustained (e.g. sports, motor
vehicle crash, pedestrian, slip and fall, environmental
exposure, etc.)?
Place of Occurrence: School, work, etc.
Initial encounters may also require, where appropriate:
Intent: Unintentional or accidental, self-harm, etc.
Status : Civilian, military, etc.
FRACTURES
Type:
o Open, closed, pathological, neoplastic disease, stress
Pattern:
o Comminuted, oblique, segmental, spiral, transverse
Encounter of care:
o Initial, subsequent, sequelae
Healing status, if subsequent encounter:
o Normal healing, delayed healing, nonunion, malunion
Localization:
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o Shaft, head, neck, distal, proximal, styloid
Displacement:
o Displaced, non-displaced
Classification:
o Gustilo-Anderson, Salter-Harris
Any complications, whether acute or delayed:
o Direct result of trauma sustained
Terminology
Pathological Fracture
Occurs in existing diseases, which weekends the bones.
Malunion Fracture
Fracture is reduced, but the bone ends did not align properly during the healing
process.
Nonunion Fracture
Is the failure of the bone ends to align or heal.
Stress Fracture
May be cause by repetitive forces applied to the bone and its supporting structures.
Comminuted
A break/splinter of the bone into more than two fragments.
Oblique
Slanted fractures that occur when a force is applied at any angle.
Segmental
A fracture in two parts of the same bone.
Spiral
Is a fracture occurring when a rotating force is applied along the axis of the bone.
Transverse
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Is a perpendicular break along the axis of the bone from a result of a force applied
at an angle.
Displaced
The bone moves in two or more parts and moves so the two ends do not line up.
Non-displaced
Then bone cracks either in part or all the way through, but maintains alignment.
Gustilo-Anderson
System is the most commonly used classification system for Open fractures.
Salter Harris
Are epiphyseal plate fractures and are common and important as they can result in
premature closure and therefore limb shortening and abnormal growth.
o Typically occurs in 10-15 years old
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CODING CHANGES
The “S” Codes are for injuries related to a single body region.
The “T” Codes cover injuries to unspecified body regions, as well as poisons.
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Injuries
Features an expanded category for injuries. Injuries are grouped by anatomical site rather
than by injury. Most are seven digits.
A seventh character extension identifies the encounter type, with:
A- Initial encounter for closed fracture
B- Initial encounter for open fracture
D- Subsequent encounter for fracture with routine healing
G- Subsequent encounter for fracture with delayed healing
K- Subsequent encounter for fracture with nonunion
P- Subsequent encounter for fracture with malunion
S- Sequela
WHEN A FRACTURE IS NOT DESCRIBED AS OPEN OR CLOSED IT SHOULD BE CODED TO A CLOSED
FRACTURE.
FRACTURES ARE CODED INDIVIDUALLY TO EACH SPECIFIC SITE.
WHEN THERE IS AFTERCARE OF AN INJURY YOU CODE THE ACUTE INJURY CODE WITH THE
“SUBSEQUENT ENCOUNTER” 7th digit.
PATHOLOGICAL FRACTURES
ICD-10 identifies for 3 different causes to pathological fractures.
o Neoplastic disease
o Osteoporosis
o Other specified disease
M80 Category should be used when it is known the patient has Osteoporosis with
a fracture.
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http://www.roadto10.org/whats-different
Burns
A new term of Corrosion, which are burns due to chemicals.
Drugs
Are divided up by: Poisoning Adverse Effect Underdoing
Is taking less medication than prescribed by a provider, resulting in a negative health
consequences.
WHEN CODING BURNS, THE BURN TO THE HIGHEST DEGREE IS CODED FIRST.
Open Wounds
ICD-10 provides a laterality distinction to be made and the type of open wound including:
Laceration, with or without foreign body
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Puncture wound with or without foreign body
Open bite
Unspecified open wound
GOOD DOCUMENTATION PRACTICE
Accident
o Where did it occur?
Assault
o What was the assault and what part of the body?
Asphyxiation
o Where and how did it occur?
Bites
o What was the bite from and where did it occur?
Burns
o Was it 1st
, 2nd
, or 3rd
degree, and what part of the body?
Trauma with one or more of the following:
o Glasgow < 14;
o systolic BP < 90;
o RR < 10 or > 29
o All penetrating injuries to head, neck, torso, extremities proximal to elbow
or knee
o Flail chest
o Combination of trauma and burns
o Pelvic fracture
o Two or more long-bone fractures
o Open or depressed skull fracture
o Paralysis
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Suspected Fracture/Dislocation Documentation
Suspected fracture or dislocation requires splinting/immobilization and renders
patient unable to be transported by another vehicle.
Includes suspected fractures or dislocations of spine and long bones and joints
proximal to knee and elbow.
The record will demonstrate history of significant trauma and/or findings to
support such suspicions.
BURNS
First-degree burns are red, moist, swollen, and painful.
Second-degree burns are red, swollen, and painful, and they develop blisters that
may ooze a clear fluid.
Third-degree burns usually are not painful because the nerves have been
destroyed. The skin becomes leathery and may be white, black, or bright red. No
blisters develop.
Heat burns (thermal burns) are caused by fire, steam, hot objects, or hot liquids.
Scald burns from hot liquids are the most common burns to children and older
adults.
Electrical burns are caused by contact with electrical sources or by lightning.
Chemical burns are caused by contact with household or industrial chemicals in
liquid, solid, or gas form. Natural foods such as chili peppers, which contain a
substance irritating to the skin, can cause a burning sensation.
Radiation burns are caused by the sun, tanning booths, sunlamps, x-rays, or
radiation therapy for cancer treatment.
Friction burns are cause by contact with any hard surface such as roads, carpets,
or gym floor surfaces.
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Burn Documentation Partial thickness burns > 10% Total Body Surface Area (TBSA).
Involvement of face, hands, feet, genitalia, perineum or major joints.
Third degree burns
Electrical, chemical, inhalation burns with pre-existing medical disorders.
POISONING
Requires cardiopulmonary and/or neurologic monitoring and/or urgent
pharmacologic intervention.
When quantity and identity of agent know to be life threatening.
When quantity and identity of agent are not known but there are signs/symptoms
of neurologic dysfunction.
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Poisoning is an overdose of a substance if the wrong substance is given or taken in
error.
Coding Changes
Types:
Poisoning, accidental
Poisoning, intentional self-harm
Poisoning, undetermined
Adverse effect
Underdosing
Underdosing
Refers to taking less medication than prescribed. Codes for under dosing should never be
assigned as a principal diagnosis. The medical condition should be coded first.
Proper administration of drug
When a medication has been taken properly, code the condition first followed by the
adverse effect of the drug “T” code.
Improper use of drug
First assign the overdose or wrong administration of drug “T” code first, followed by
manifestations that occurred, including if abuse, or dependence of the drug.
Intent
If the intent is not documented or not known than the “accidental intent” ICD-10 code is
used. The Undetermined intent is only used when there is not documentation that shows
it is undetermined.
HEAT EXHAUSTION
Excessive loss of salts (electrolytes) and fluids due to heat, leading to decreased blood
volume that causes many symptoms, sometimes including fainting or collapse.
Symptoms:
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Dizziness
Light-headedness
Weakness
Fatigue
Headache
Blurred Vision
Muscle Aches
Nausea/Vomiting
HYPOTHERMIA
Results when the body loses more heat than can be replaced by increasing
metabolism or by increasing warming from external sources, such as a fire or the
sun.
Initial symptoms include intense shivering and teeth
chattering.
As body temp falls further, shivering stops and
movements become slow and clumsy, reaction time is
longer, thinking is blurred, and judgment is impaired.
MEDICAL DEVICE FALIURE
Life- or limb-threatening malfunction, failure or complication.
Malfunction of internal pacemaker, internal defibrillator, implanted drug delivery
device, O2 supply malfunction, and orthopedic device failure.
EXTERNAL CAUSES OF MORBIDITY
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External Causes of Morbidity
Captures the Cause of the Injury or Health Condition.
The Intent
o Unintentional or accidental;
o Suicide or assault.
The Place the Even Occurred.
The Activity of the Patient at the Time of the Event.
The Person’s Status
o Civilian
o Military
o Most codes require a 7th character. PER CMS Website
If you have not been reporting ICD-9-CM external cause codes, you will not be
required to report ICD-10-CM codes found in Chapter 20 unless a new State or
payer-based requirement about the reporting of these codes is instituted. If
such a requirement is instituted, it would be independent of ICD-10-CM
implementation.
In the absence of a mandatory reporting requirement, you are encouraged to
voluntarily report external cause codes, as they provide valuable data for
injury research and evaluation of injury prevention strategies.
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Factors Influencing Health Status and Contact Health Services
o Z Codes Represent Reasons for the encounters.
o These codes are provided for occasions when circumstances other than a disease.
o Injury, or external cause classifiable to the other categories.
o This occurs two ways:
o When a person who may or may not be sick encounters healthcare for
some specific purpose; or
o When circumstances or problem is present which influences the person’s
health status but is not in itself a current illness or injury.
Complete Injury Coding
BED CONFINED
The patient must meet all of the following three criteria:
Unable to get up from bed without assistance.
Unable to ambulate
Unable to sit in a chair (including wheelchair)
Non-emergency ambulance transportation is not covered for patients who are
restricted to bed rest by a physician’s instructions but who do not meet the above
three criteria.
There should be a narrative description that describes the reason the term “bed
confined” is being used.
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DOCUMENTATION
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Documentation
The patient’s condition should be coded based on the documentation from the
personnel on scene.
Non-Emergency clearly has to already be specific to the patient’s condition and
need for the ambulance.
The Diagnosis Code is to support the reason for transport.
Medical Necessity
Medicare Benefit Policy-Chapter 10-Ambulance
When the patient’s condition requires the vehicle itself and/or the specialized
services of the ambulance personnel were provided and clear clinical
documentation in the patient’s ePCR validates their medical need and their
provision.
The patient’s condition, as well as changes in that condition and the treatment
provided, must be recorded.
These are conditions which may establish medical necessity:
o Patient had to be transported due to an emergency (as the result of an
accident or injury).
o Patient needs to be restrained.
o Patient is unconscious or in shock.
o Patient requires oxygen or other emergency treatment.
o Exhibits signs and symptoms of acute respiratory distress or cardiac
distress.
o Patient needs to be immobile because of fracture or the possibility of
fracture.
DOCUMENTATION
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o Patient sustains an active stroke or MI.
o Patients experiences severe hemorrhaging.
o Patient was bed confined or
o Needed to be moved by stretcher.
Emergency Documentation
Chief Complaint
History of Present Illness (HPI) has always been critical to obtain
Past Medical History (PMH)
Any pertinent documentation from family or facility
ALS Assessment if performed, documented
Vital signs
Assessment of head to toe
Pain Assessment
Treatment and interventions
Successful or Unsuccessful Attempts
How was the patient moved
Patient status while transported
Non-Emergency
For nonemergency transports, the crew should generally focus more on the patient’s
deficits that prevents transportation by another means, rather than what may appear
to be the main diagnosis.
WHY DO YOU HAVE TO BE THERE?
Pain: What was the scale, where is the pain?
Paralysis: Where? Left? Or Right?
DOCUMENTATION
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Fall Risk: Is the patient a danger to their self or to others and why?
Pressure
Ulcers: Where? Left or Right? Upper or Lower? And What is the stage?
Oxygen: Is the patient unable to administer oxygen and why?
Bed
Confined: Are they able to sit, stand or ambulate?
Most
Important: Does the patient need to be transported by Ambulance?
MOVING FORWARD
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Moving Forward
Pull your top 25-50 ICD-9-CM Diagnosis Codes
Crosswalk them with available resources
Identify in your organization where ICD-9-CM’s are currently utilized and will need
to be updated, i.e. NEMSIS.
MOVING FORWARD
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• Evaluate the CMS and your MAC’s website.
• Order ICD-10 Code Books and various other resources to help educate your
team.
• Watch for various webinars available for team training.
• Have billing, IT and Operations collaborate in implementing of ICD-10’s.
• When new procedures, protocols, medicines or equipment is being used,
provide in-services for billing staff.
MOVING FORWARD
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• Determine if there are weaknesses in your documentation and begin correcting
immediately.
• Update Compliance Plans and policies and procedures to reflect ICD-10-CM.
• Consider implementing a query processes for your medics when billing staff
needs clarification. This could make a difference in medical necessity and
ensuring proper billing.
• Have a clear understanding how your software vendor is implementing ICD-
10-CM’s.
• If you have contracts with Commercial Carriers, verify their language and
ensure the level of specificity they will require.
• Monitor your MAC’s websites for updates and changes.
MOVING FORWARD
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• Update you billing system with ICD-10-CM’s, test running reports, claims and
files.
• Once ICD-10-CM’s are implemented continue to monitor system to ensure
claims are going out the door appropriately.
• Watch for denials due to ICD-10-CM’s and monitor closely.
MOVING FORWARD
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If the payors receive non-compliant codes OR incorrectly associate ICD-10-CM codes in
their systems…then major disruption…and if there’s disruption…
Provider has to call the Payor
Payor answers questions, request more information.
Claims are delayed.
Disruptions in cash flows.
No one is happy.
It is everyone’s best interest to work toward a seamless transition.
RESOURCES
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Resources
RESOURCES
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RESOURCES
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APPENDIX
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Appendix
American Ambulance Association Top Ambulance ICD-10-CM Diagnosis Codes
American Ambulance Association Condition Code List ICD-10 Updated
CMS/AMA Announces Efforts to Help Providers Get Ready for ICD-10
CMS Letter to Providers Regarding ICD-10’s
CMS Clarifying Q&A’s Related to CMS/AMA Announcement Regarding ICD-10’s
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